Metaphors We Live By (and Through)

In their influential book Metaphors We Live By, George Lakoff and Mark Johnson make the point that metaphors are pervasive in human cognition. They in fact structure “thought and action.” A metaphor typically defined as “understanding and experiencing one kind of thing in terms of another” are more than “devices of poetic imagination…rhetorical flourish” or a “characteristic of language alone.” They are part and parcel of human cognition. Human cognition is “fundamentally metaphorical in nature.” What we see (and don’t see), our interpretations, interpolations, extrapolations, inferences funnel through our metaphorical concepts. These concepts – once embedded and established – retreat into the background, become invisible and unquestioned to and by our consciousness. They serve as the lubricant for fluid and frictionless thought. However, the same properties of invisibility and unquestionability can mislead people into confusing the metaphorical relationship for reality, and consequently, leading to blindspots, missed opportunities, suboptimal outcomes, and system traps. Thus, an analysis and excavation of metaphorical concepts in a domain is an exercise in understanding and explaining that domain.

By many accounts, modern medicine and healthcare grounded in the metaphors of scientific reductionism, industrialization, neoclassical economics, and military have been immensely successful endeavors. Examples and supporting data documenting these successes abound. Antibiotics have rendered previously deadly bacterial infections treatable, vaccines and vaccination programs protect against viral infections, immunotherapies are making inroads against cancer and autoimmune diseases, advances in techniques and materials have made surgical interventions increasingly less traumatic and non-invasive. Advances in diagnostic imaging and biomarker testing have given us unparalleled access and insight into the anatomy, physiology, and pathology of the body. The benefits of these technologies are borne out in statistical measures such as an increase in life expectancy and a decrease in mortality from the scourges of cardiovascular diseases and cancer, and child mortality.   

Despite this progress, not all is well. There is a persistent discontent from patients, an “epidemic of burnout” of physicians, and evidence of stagnation in health measures. Despite the hundreds of billions of dollars spent on cancer, cardiovascular, neurodegenerative, and metabolic diseases they remain the leading causes of morbidity and mortality in the United States. Life expectancy gains from the last century have mostly plateaued. There is also data that supports the claim that many of the extra years of life are spent sick, immobile, and debilitated. In effect trading quantity of life for quality of life, expanded morbidity for compressed mortality. Although the volume of medical data continues to increase, precision medicine remains illusory and cures for major disease classes remain aspirational. Despite the billions of dollars spent, heart disease, diabetes, cancer, neurodegenerative diseases remain significant causes of morbidity and mortality. Moreover, as the Covid-19 epidemic showed, the specter of microbial disease and antibiotic resistance looms like the Sword of Damocles. 

Are the mixed outcomes just a symptom of the growing pains of a system transitioning towards a new and higher optimum? Or are the plateauing trajectories, the marginal returns on investment a sign of a system that has peaked? More than likely it is some combination of the two. If so, then an examination and reappraisal of the dominant metaphorical concepts imported from the paradigms of scientific reductionism, industrialization, neoclassical economics, and the military would serve as a beneficial exercise. Metaphors such as the patient as a consumer, physician as a provider, healthcare delivery, the cost disease, population health, standard of care, the gold standard, a silver bullet, a magic bullet, the body as a mechanism or a machine or data, war on disease x, defensive medicine, and disease as a disorder. If metaphorical concepts structure our “ways of seeing” and “create realities for us,” then an exploration of “new metaphors have the power to create new realities.”