YALE JOURNAL OF BIOLOGY AND MEDICINE 76 (2003), pp. 87-95.

Copyright © 2003. All rights reserved.

HUMANITIES AND MEDICINE

Metaphor and Medicine:

Narrative in Clinical Practice

Jack Coulehan
Department of Preventive Medicine, State University of New York at Stony Brook,
Stony Brook, New York

For decades it seems that the art has cies in humanism, professionalism, com-
been slipping away from medicine. Like the munication, evidence-based practice, and
ancient Greeks, who lamented the passing social responsibility, and it requires med-
of the Golden Age, contemporary physi- ical schools and residencies to develop
cians, educators, the general public, and curricula that teach these competencies.
especially the sick mourn the loss of the Dehumanization can best be stated in
human dimension of medical practice. narrative terms; i.e. nowadays medicine
Fragmentation, subspecialization, lack of tends to ignore or minimize the role of nar-
continuity, technological demands, burgeon- rative in illness and healing. Narrative
ing patient volume, institutional stress, and, medicine is “medicine practiced with the
most recently, managed care appear to have narrative competency to recognize, interpret,
caused recent generations of physicians to and be moved to action by the predica-
devalue relationship-based medicine in ments of others” [6]. Medicine is largely
favor of procedures and machines [1, 2]. about storytelling and interpretation, and
Commentators have responded to this narrative, metaphor, and symbol are funda-
unfavorable diagnosis with various pre- mental tools of the trade [7-9]. Ill persons
scriptions. One the earliest was the “bio- experience meaning in their illnesses, they
psychosocial model,” which George Engel see themselves as characters in a life nar-
put forth as a new paradigm to replace the rative, and they approach medicine as a vast
reductionistic, disease-oriented “biomed- network of healing symbols.
ical model” with a more holistic, illness- Patients understand their illnesses in a
centered perspective [3]. The competency- narrative way whether their physicians
based initiative for medical education realize it or not. If this is so, and if physi-
sponsored by the American Association of cians ignore or devalue narrative, then
Medical Colleges and the American Coun- health care is bound to suffer. From the
cil for Graduate Medical Education is the patients’ perspective, narrative incompe-
most recent proposed therapy [4, 5]. This tence causes widespread dissatisfaction,
innovative regimen parses the art of medi- distrust, and failed expectations. Within
cine into a series of topics and competen- the profession, it leads to the persistent

To whom all correspondence should be addressed: Jack Coulehan, M.D., M.P.H.,

Department of Preventive Medicine, HSC L3-086, State University of New York at Stony
Brook, Stony Brook, NY 11794-8036.
87
88 Coulehan: Metaphor and medicine: narrative in clinical practice

belief that something valuable is lost; i.e., from cancer are often suspected of having
the old days were better. Today’s doctors brought it upon themselves (“cancer-
are taught to objectify their patients and to prone”). On the other hand, medical prac-
remain emotionally detached, but in so doing titioners approach cancer with a different
they may not diminish their ability to heal, metaphor based on military images. Cancer
they may also harm themselves by develop- is aggressive and invasive; it seeks to infil-
ing chronic stress, emotional numbness, trate and colonize by battering down the
and burnout. body’s defenses.
This essay is a brief reflection on the Because of these metaphors, especial-
centrality of narrative and metaphor in ly the first, people who suffer from cancer
medicine. I begin with the anti-narrative experience isolation and shame. They don’t
position as stated by Susan Sontag, a non- talk about their illness. They delay seeking
physician, whose sentiments are similar to, medical care. Their families and friends
but more eloquent than, many physicians shy away from them. In Illness and
who view medicine as a purely technical Metaphor Sontag also examined the nine-
enterprise [10]. I then critique Sontag’s teenth century cultural beliefs about tuber-
“strip illness of metaphor” position by cit- culosis and found that they, too, detracted
ing traditional Navajo medicine, a system from a “true,” i.e., scientific, understanding
of healing built almost entirely on narra- of the disease. Ten years later, in AIDS as
tive and metaphor. I claim that narrative is Metaphor (1988), the author extended her
(or ought to be) an essential component of anti-metaphorical analysis to HIV/AIDS,
contemporary medicine, inextricably bound which, she claimed, had largely replaced
to the technical or machine-based compo- cancer as the unspeakable disease in our
nent, like the two snakes that are entwined society because it was associated with
on the caduceus. In the final sections of the homophobia and believed to be a punish-
essay, I provide some examples of the ment from God [11].
importance of language and metaphor in Sontag’s central claim in both books is
everyday practice and discuss detachment that illness should be stripped of metaphor.
as a barrier to, and empathy as a facilitator She wrote, “My point is that illness is not
of, narrative medicine. a metaphor, and that the most truthful way
of regarding illness — and the healthiest
WHO’S AFRAID OF SUSAN way of being ill — is one most purified of,
SONTAG? most resistant to, metaphoric thinking…
human beings can and should think of ill-
After surviving a bout with breast can- ness from a purely biochemical or physio-
cer in the mid-1970s, the literary critic and logical perspective” [10, p. 3]. Thus, there
novelist Susan Sontag published a book ought not be any personal or existential
entitled Illness and Metaphor [10]. This meaning attached to illness, nor cultural
work was distinguished by its crisp, ele- images associated with illness. From this
gant prose style; by its rich array of literary perspective, medicine should avoid metaphor
and historical allusion; and, ultimately, by like the plague.
the sensation it caused among our post- Though elegant in style, Sontag’s
modern intelligentsia. Sontag made two books are deficient in research and full of
central claims. First, she argued that the faulty reasoning. She fails to place her con-
disease called “cancer” evokes in the popu- clusions about the shamefulness of cancer
lace a pervasive cultural myth or metaphor. in an historical context, or to provide data to
Cancer is an obscene, unspeakable, and support her statements that cancer sufferers
shameful condition. The disease is closely preferentially fail to seek medical treat-
related to sin or guilt. People who suffer ment [12]. Moreover, she generalizes from
 Coulehan: Metaphor and medicine: narrative in clinical practice 89

her analysis of a few supposedly negative mony with himself, his family, his clan,
cultural metaphors to conclude that, there- and the network of relationships that con-
fore, all illness metaphors must be nega- stitute the Navajo Way. To be healed is to
tive. Finally, she fails to address the human have that harmony restored. In order to
need to experience one’s life as a story and accomplish this, the patient, first, has to
to attribute meaning and context to impor- consult a diagnostician who, by means of
tant life events. She seems to take for hand trembling or other forms of divina-
granted the reductionistic myth that the tion, establishes the cause of the illness.
more a person approximates a reasoning The diagnostician then prescribes an
machine, the better off he or she will be. appropriate ceremony or “Sing,” which
As a young primary care physician consists of storytelling, chanting, sand
when I first read Illness and Metaphor, I painting, and other elaborate rituals that
had a few observations of my own about may go on for three to nine days. This for-
the subject matter. First, it seemed obvious mal Navajo healing system is almost
that the monolithic cancer metaphor didn’t entirely symbolic. The ceremonies consist
exist. Yes, of course, some people delayed of re-telling myths of the creation and sal-
seeking medical care, or chose to be “non- vation of the Navajo people by gods like
compliant,” because their beliefs make them Spider Woman, White Shell Woman, and
terrified of the disease or its treatment; but the Hero Twins [13, 14].
this happened no more often with cancer There was a seeming paradox in
than with other diseases. Indeed, almost Lower Greasewood. The Navajo community
every patient with serious illness has a enthusiastically accepted Western medical
complex mixture of personal, religious, treatment and flocked to the clinic. Yet,
cultural, and media-based beliefs regard- when a person was seriously ill, he or she
ing his or her condition; some positive, also undertook the complex arrangements
some negative; some that contribute to for a traditional healing ceremony. A Sing
healing, others that might delay it. No matter required the presence of the ill person’s
how eloquently Susan Sontag declared, extended family and other clan members,
“Do not attribute a meaning to illness,” I who would have to set aside their jobs and
just couldn’t imagine her claiming many other responsibilities to participate in sev-
converts. Moreover, I had just returned eral days of chants, prayers and dances.
from spending two years in northern The family would also have to butcher
Arizona on the Navajo reservation, where I sheep to feed the participants, and pool
was the only physician at Lower Grease- their resources to pay the hataali or Singer
wood Clinic and Boarding School. Living and his assistant. What led them to do all
in the Navajo community, I found myself this when the Navajo were entitled to free,
surrounded by a very effective traditional state-of-the-art medical care through the
healing system based almost entirely on United States Public Health Service?
narrative and metaphor. It seemed clear that, At first I thought the benefits were
among the Navajo, poetry could heal. It cer- entirely social (i.e., getting together with
tainly wasn’t harmful. If that is so, I asked, friends and family) or psychiatric (i.e.,
why is it harmful to employ metaphor and treatment of mental disorders). But with
meaning in Western medicine? time I realized that an appropriate Sing
could “heal” any seriously ill person, even
“MAY I WALK IN BEAUTY” a patient with terminal cancer, because
prolonging life isn’t necessarily the aim of
Among the Navajo, all serious illness Navajo medicine. Human beings, like plants
results from disharmony. To become sick, and animals and the visible world itself,
a person has somehow fallen out of har- participate in a cycle of birth, develop-
90 Coulehan: Metaphor and medicine: narrative in clinical practice

ment, maturity, and decline. This cycle in fact, that he saved a man whose life was
constitutes the harmonious, natural way of the forfeit to the gods. In retribution, Zeus
universe. Attempting to extend an elderly struck Asklepios dead with a thunderbolt.
person’s life beyond its natural span might However, later (perhaps as a result of
well be seen as disharmonious or harmful, Apollo’s influence at the Olympian court),
rather than healing; what the ceremony Asklepios was made immortal and became
would do was to bring the dying person into the god of medicine. In keeping with this
a harmonious relationship with the impor- mythic narrative, Asklepios healed his
tant persons and values in his or her life. patients through the mediation of priests
Moreover, I learned that, for the and ceremonies, and utilized modalities
Navajo, penicillin shots and arthritis pills interpretation of dreams and visions.
were not value-free scientific treatments. On the other hand, Hippocrates (470
Rather, the introduction of Western medi- to 410, BCE), the father of scientific medi-
cine had caused the Navajo to incorporate cine, was no myth. He did, indeed, found a
its procedures and “ceremonies” into their tradition of medicine devoted to naturalistic,
cultural narrative. For example, they devel- empirical explanations of disease. He
oped the belief that antibiotics (primarily apparently discarded supernatural causation,
“shots,” since tablets were thought to be less and focused on behavioral and environ-
effective) were very efficient in alleviating mental intervention. Nonetheless, the oath
the symptoms of pneumonia, but did not developed by the Hippocratic school of
address the disharmony that allowed the physicians acknowledges the power of myth
person to become ill. When fever and and narrative, rather than decrying it; the
cough were gone, important questions oath begins by pledging commitment to the
remained: “Why me? Why was I vulnerable symbolic world, “I swear by Apollo the
to this illness? What does my life mean in physician, and Asklepios, and Health, and
the face of this illness?” Thus, even though All-heal, and all the gods and goddesses…”
Western medicine had been incorporated I suspect that the Hippocratic physicians
into the patients’ cultural expectations, were professionals who understood the
they would need to arrange a “Sing” in importance of narrative skills in their day-
order to address the more narrative dimen- to-day practices.
sions of illness; i.e., to re-experience them- The original caduceus of Asklepios,
selves as part of a meaningful story. which became the symbol of the medical
profession, consisted of a single snake of
ASKLEPIOS AND HIPPOCRATES healing entwined around a staff. However,
in the United States relatively recently, we
I find a parallel in ancient Greek medi- have added a second snake to the caduceus
cine between the narrative or symbolic [15]. Although the real historical reason is
strand in healing, as exemplified by the quite otherwise, I like to imagine that our two
Navajo, and the empirical or instrumental snakes represent the narrative (Asklepian)
focus that we strive for in scientific medi- and instrumental or empirical (Hippocratic)
cine, and of which Susan Sontag approves. strands of medicine, entwined in this uni-
The myth of Asklepios, the god of healing, fied symbol of the healing art.
holds that Asklepios was once mortal, the They are inextricably bound. Just as
son of the great god Apollo and a human the Navajo patient views Western medicine
woman named Coronis. Apollo directed from the perspective of her belief system,
that Chiron, who supervises the interface thus incorporating antibiotics and surgery
between life and death, teach his son the into her narrative and rendering them a
skills of healing; and Asklepios became meaning beyond their strictly instrumental
world’s most powerful healer, so powerful, effects, so also any other patient brings his
 Coulehan: Metaphor and medicine: narrative in clinical practice 91

or her beliefs and values to the words spo- single most important element of diagnosis
ken (or unspoken) and actions performed and the key to effective therapy. Harrison's
by medical practitioners. Textbook of Medicine makes this point in
If the physician understands this its first few pages, before devoting the next
dynamic, he or she is likely to develop and two thousand pages exclusively to organ
utilize narrative skills in practicing medi- systems and biochemistry.
cine. Narrative competence leads to better Another example is the statement,
clinical outcomes, e.g., more accurate diag- “The patient is a poor historian.” The stan-
noses, enhanced adherence to therapy, and dard medical meaning of this sentence is
greater patient satisfaction. Alternatively, that the patient is unable to tell the doctor
if the physician believes that real medicine in a coherent or understandable way what is
is confined to the Hippocratic or instru- wrong; it blames the patient. However, isn’t
mental dimension, his or her influence on the doctor is the professional whose respon-
the patient is bound to be less predicable, sibility it is to reconstruct a relevant illness
depending on whether their beliefs happen story? If so, wouldn’t it be more reason-
to be synergistic or antagonistic, or whether able to consider the doctor the historian
they happen to exchange the right words or and the failure, if any, largely the doctor’s?
the wrong words, and so forth. In other After all, he or she is expected to have the
words, by subscribing to a culture of medi- communication skills and narrative com-
cine based on the belief that medicine is petence to elicit and understand stories of
above or beyond culture, the doctor is sickness.
bound to be a less effective healer. With regard to the iatrogenic suffering
The following paragraphs suggest a few caused by inappropriate words in medicine,
of the ways that narrative elements — words, the internist Eric Cassell coined the apho-
images, metaphors, and symbols — influence rism, “Sticks and stones may break your
and structure day-to-day practice, even bones, but a word can kill you.” Consider
when physicians may focus their attention casual (or intentional) statements like the
elsewhere and have no idea what is happen- following: “You have a time bomb in your
ing in the patient encounter, or in their inter- chest,” “The next heartbeat may be your last,”
action with other health care professionals. “Your life is hanging by a thread,” and
“There is no choice. We have to operate.”
WORDS AND IMAGES These common examples taken from the
field of cardiology, illustrate well how
Common words and phrases in medi- words — perhaps spoken with the best of
cine reflect a culture that objectifies intentions — can cause iatrogenic harm
patients. For example, the term “history
taking” reflects the ambiguous position THE METAPHORS OF MEDICINE
that narrative enjoys in contemporary
medicine. “History implies objectification A number of writers have looked
of the patient's story, suggesting that “it” is beyond the day-to-day language to discov-
an entity we might discover if we search er the basic models or metaphors we use
aggressively enough, like a “black box” when thinking about medicine [16-17].
among the wreckage of a patient’s life. There are several such metaphors that to a
“Taking” implies that the doctor violates large extent generate our vocabulary of the
her patient. She wrenches the story, whisks patient-physician relationship. Table 1 lists
it away, as if she were pulling a bad tooth three of the most prominent of these and
or removing a hot appendix. Despite this some of their implications. Contemporary
phraseology, in theory, at least, authorities medicine has officially disavowed the
agree that talking with the patient is the parental (or paternalistic) metaphor, which
92 Coulehan: Metaphor and medicine: narrative in clinical practice

Table 1. Medical Metaphors

War metaphor War statements

Disease is the enemy “I treat all my patients aggressively…”
Physician is a warrior captain “He’s a good fighter.”
Patient is a battleground “The war on cancer.”

Parental metaphor Parental statements

Disease is a threat or danger “She’s too sick to know the truth…”
Physician is a loving parent “We don’t want him to lose hope.”
Patient is a child

Engineering metaphor Engineering statements

Disease is malfunction “He’s in for a tune-up.”
Physician is an engineer or technician “Something’s wrong, doc… you fix it.”
Patient is a machine “We need to ream out your plumbing.”

was perhaps the most prevalent way of SYMBOLS OF HEALING

thinking about the patient-physician rela-
tionship in the past. Biomedical ethics William Osler wrote to his fellow doc-
teaches us to respect our patients as adult tors in 1910 about the “faith that heals.” In
decision makers, rather than simply looking his essay, Osler noted that, while his col-
out for their best interests as we would with leagues viewed the practices and parapher-
children. However, the relative demise of nalia that filled Johns Hopkins Hospital as
paternalism (which at least implied a human, objective and scientific “givens,” patients
caring interaction) has been accompanied inevitably experienced them as a vast net-
by the rapid advance of the engineering work of symbols that promote healing.
and war metaphors, both of which tend to [18] Consider the contemporary hospital
objectify and dehumanize the patient. — the white coats, stethoscopes, and beepers.
Of course, each of these metaphors is The ritual of daily rounds. The ceremony
true in a sense. Each sheds some light on of physical examination. Consider the
the patient-physician relationship, but also nuclear magnetic imager as an oven-like
casts a shadow. While capturing one char- oracle that sees inside the soul and one’s
acteristic of illness or healing, each one emergence from this machine a type of res-
downplays or ignores certain other fea- urrection. Or what about the treadmill? A
tures. There are also other, more humane, Sisyphean task that patients set their hearts
metaphors for medicine; for example, against. All of these procedures, whatever
physician-as-teacher, or physician-as-reader their intended scientific effect, are also
or editor. Obviously, we need many such symbols or ceremonies that involve the
images to capture the truth, but we must manipulation of symbols. As Osler wrote,
understand that none are exclusive, and some “Nothing in life is more wonderful than
are more useful in healing than others. faith — the one great moving force which
 Coulehan: Metaphor and medicine: narrative in clinical practice 93

we can neither weigh in the balance nor to treat family members and close friends.
test in the crucible. Intangible as the Yet, there is surely a vast chasm between
ether…” [18]. He went on to explain that the pole of ignoring the screams and the
the symbolic network of modern medicine opposite pole of being impaired or devas-
generates “an atmosphere of optimism, tated by them.
and cheerful nurses, that work(s) just the Dr. Adams demonstrates what is
same sort of cures as did Asklepios” [18]. called detached concern. He is concerned
about his patient’s welfare, yet remains
DETACHMENT VS. CONNECTION emotionally detached. This stance has
become normative for medical education;
“Oh, Daddy, can’t you give her some- i.e., we now claim that doctors should
thing to make her stop screaming?” asked adopt an attitude of detached concern
Nick. toward their patients [20, 21]. Yet, unop-
“No. I haven’t any anesthetic,” his posed detachment leads to objectification
father said. “But her screams are not of the patient as a person — and not only
important. I don’t hear them because the patient’s body. Since the body is the
they’re not important” [19]. primary source of “objective” data, the
I suggest that our modern commit- person becomes less relevant to medical
ment to detachment and objectivity serves practice, except in terms of “soft” concepts
as a barrier to narrative in medicine. In like bedside manner. Alternatively, if per-
Ernest Hemingway’s “Indian Camp,” Nick sonal narrative is important, how can one
Adam’s father makes a nocturnal trip obtain, assess, or interpret such subjective
across the lake to deliver an Indian woman data without developing a type of connec-
who is having a difficult labor. The young tion with the patient that appears to be pre-
Nick goes along for the ride. He experi- cluded by the term “detached concern”?
ences a natural empathy with the woman, I like to characterize this tension
who is writhing in pain. Yet, his physician between subjectivity and objectivity by
father remains detached, explaining that borrowing the words tenderness and
the patient’s screams are “not important.” steadiness from Thomas Percival, the
He understands the pain from a physiolog- British Enlightenment physician who
ical perspective (“all her muscles are try- wrote the first modern synthesis of med-
ing to get the baby born”), but considers it ical ethics [22, 23]. In the first chapter,
a potential distraction. He believes that by Percival enjoins physicians to “unite ten-
listening to the screams, he would compro- derness with steadiness” in the care of
mise his technique. patients [23]. Under “steadiness” Percival
This quotation illustrates in a dramat- includes the intellectual virtue of objectivity
ic way the tension between detachment or reason, along with moral virtue of
and connection in medical practice. Nick’s courage or fortitude. By “tenderness” he
father is evidently a kindly man, yet he means humanity, compassion, fellow feel-
believes that emotional vulnerability will ing, and sympathy. In his letters, Percival
impair professional performance. There is, contrasts the “coldness of heart” that often
of course, a factual basis to the belief that develops in practitioners who do not culti-
too much involvement with another per- vate such virtues with the “tender charity”
son’s suffering impairs one’s functioning. that the moral practice of medicine requires.
Indeed, the patient’s husband, who is “This coldness of heart, this moral insensi-
wounded and lying on a bunk in the same bility, should be sedulously counteracted
cabin, eventually commits suicide because before it has gained an invincible ascen-
he cannot bear the weight of his wife’s suf- dancy” [23]. The contemporary emphasis
fering. Similarly, physicians are ill advised on detachment and objectivity promotes
94 Coulehan: Metaphor and medicine: narrative in clinical practice

coldness of heart and serves as a barrier to or process of recognizing the other. Some
narrative medicine. writers emphasize the intellectual or cogni-
tive dimension of empathy. The empathic
THE EMPATHIC CONNECTION practitioner attends carefully to the other’s
verbal and nonverbal expressions, inter-
The key to finding an appropriate bal- prets them, and then forms hypotheses
ance between tenderness and steadiness, or about the other’s subjective experience.
subjectivity and objectivity, lies in devel- The practitioner then shares with the other
oping three core personal qualities: (a) the fact that he or she has been “heard,”
empathy — the ability to understand accu- while at the same time testing the hypothe-
rately the patient’s feelings and experience, ses by further questioning: Is this what you
and to communicate that understanding; really mean? Is that how you really feel?
(b) genuineness — the ability to be yourself But there is also a strong affective
in a relationship, without hiding behind a dimension of clinical empathy. You can’t
role or facade; and (c) unconditional positive know how a patient is feeling in a given
regard — the ability to accept and validate situation without, in some sense, actually
patients just as they are. I am unable to dis- experiencing that feeling yourself. Spiro
cuss these qualities in detail here, but I expressed the affective aspect of empathy
would like to make a few comments on when he wrote, “empathy is more than know-
clinical empathy, which I take to be a teach- ing what we see, it is the emotion generated
able and learnable set of skills [24, 25]. by the image” [28]. Empathy requires the
In A Fortunate Man, John Berger doctor to be emotionally engaged and
sketches the life of John Sassall, a general “experience the other’s attitudes as presence’s,
practitioner in a rural part in England [26]. rather than as mere possibilities” [28]. In other
For Sassall the doctor’s central task is an words, interplay of feelings is an essential
“individual and closely intimate recogni- part of an empathic connection with a
tion” of the patient: “If the man can begin patient. One cannot fully recognize or under-
to feel recognized — and such recognition stand the patient without experiencing
may well include aspects of his character emotional involvement [22].
which he has not yet recognized himself —
the hopeless nature of his unhappiness will CONCLUSION
have been changed…” [26]. Sassall is
acknowledged to be a good doctor “because Illness and healing inextricably bound
he meets the deep but unformulated expec- to narrative, meaning, and metaphor. The
tation of the sick for a sense of fraternity. “strip illness of metaphor” metaphor sug-
He recognizes them.” In fact, Sassall, gested by Susan Sontag, and embodied in
“does not believe in maintaining his imagina- contemporary medical practice, damages
tive distance: he must come close enough patient, doctor, and the healing relationship
to recognize the patient fully” [26]. This because it promotes detachment, objectivity,
recognition of the patient’s subjectivity is a and autonomy to the exclusion of connection,
function of empathy, which creates the subjectivity, and solidarity; and teaches
connection that the narrative dimension of patients and doctors to ignore the power of
medicine requires. words and stories to harm, as well as to heal.
Zinn defined empathy as “a process The Hippocratic and Asklepian dimen-
for understanding an individual’s subjec- sions of healing, as suggested by the two
tive experiences by vicariously sharing that snakes of the caduceus, not only inevitably
experience while maintaining an observant co-exist, but also are potentially synergistic.
stance” [27]. There are several possible In contemporary practice the narrative
ways of looking at this “vicarious sharing” dimension is often ignored because of our
 Coulehan: Metaphor and medicine: narrative in clinical practice 95

12. Clow B. Who’s afraid of Susan Sontag? Or,

focus on detachment and objectivity. How- the myths and metaphors of cancer recon-
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