“Suffer the Little Children”: Analyzing Uses and Abuses of Metaphorical Language in Pediatric Medicine
Moderator: Daena J. Goldsmith, PhD, Professor of Rhetoric & Media Studies, Lewis and Clark College
Panelists: Robyn Boeré, PhD, Associate Lecturer in Christian Ethics, St. Andrews University; Tyler Tate, MD, Assistant Professor in Pediatrics, Center for Ethics in Health Care, Oregon Health and Science University; and Katelyn MacDougald, Georgetown University
Language use in health care is frequently taken for granted. Unlike other features of medical practice, such as diabetes management or research in health policy, the language of health care generally sits in the background, the substrate for other, more concrete, objects of empirical investigation.
This lack of focus is a mistake. It stems from a deformed style of reasoning which treats anything that is not physical as though it were unreal. But language is very real. As Hans- Georg Gadamer noted, “You must realize that when you take a word in your mouth, you have not taken up some arbitrary tool which can be thrown in a corner if it doesn’t do the job, but you are committed to a line of thought that comes from afar and reaches on beyond you.” (1982, pp. 547–548)
Language not only conveys information, but also shapes our perspectives, our experiences, and our very selves. This is especially true of metaphor. For example, when Christian believers call God a father, a shepherd, or a lion, the metaphor itself contributes to their mode of worship and understanding of self in relationship to the divine. Language, particularly metaphor, constitutes social reality. Thinking deeply about the language we use is thus crucial to medical ethics, especially in the realm of pediatrics, where children are being formed and forming their selfhood for the first time.
There are limited studies examining the uses of metaphor in medical discourse. However, existing studies suggest that patients’ behavior and lived experience of illness are partly determined by the choice of metaphor used in clinical communication. For instance, some recent work has highlighted a link between anxiety and the use of war metaphors among cancer patients. Other studies suggest a link between particular metaphorical descriptions of cancer, and patients' likelihood of adopting preventive behaviors. Yet many of these studies are hamstrung by a reliance on crude and underdeveloped accounts of language. They make the mistake of assuming that metaphor is an aberration of linguistic form, standing opposed to “pure,” “simple,” or “literal” language. On this basis, they make universal pronouncements on acceptable metaphors, failing to understand the contextual and relational nature of language use. Consequently, insofar as many studies fail to account for the rich and ever- evolving ways that metaphors build and constitute human social reality, they are limited in impact and scope.
Our interdisciplinary panel—composed of a linguist, a physician-ethicist, and theological ethicist—will examine the use of metaphor in pediatric medicine, with its complex matrix of relational voices, and consider the ways that children receive, use, and co-construct metaphoric structures. We focus on pediatrics for two reasons. First, there is little scholarship on pediatric metaphor use. Second, children are uniquely susceptible to the power of language to construct self-understanding and social identity. We will begin by identifying the explicit and implicit definitions of ‘metaphor’ employed in the medical ethics literature. In doing so, we will challenge the prevalent conception of metaphoric language as the antithesis of literal language, instead revisioning metaphoricity as the antidote to canonicity—the quality of having entrenched, conventionalized meaning within a given discourse community. The imperfect mapping between subjective experience and canonical language leaves space for what we call metaphorical ruptures, tears in the discursive fabric through which raw meanings can emerge. Metaphoric language is, on this view, not that whose meaning diverges from its truer or more literal semantic denotation, but that by which the lived experiences of social actors are transferred to unconventional but interpretable linguistic forms. In view of this revisioning, we will draw from the toolkit of linguistic discourse analysis—specifically, the concepts of framing and positioning—to examine publicly available video excerpts of communication with and around chronically ill children. Our analysis will highlight the ways that metaphoric structures are locally deployed and negotiated in interactive frames while illustrating how participants in pediatric relationships use canonical language to position subjects within the cultural storylines of illness and treatment at play in the broader discourse community.
This framework for understanding metaphorical language within clinical encounters will set the stage for an ethical evaluation of particular canonical storylines used in pediatric care. Military language dominates the cultural discourses surrounding pediatrics, from advertisements that declare “sick isn’t weak; sick fights back” to assertions that “my child is a fighter.” We will discuss the potential harms this dominance causes, both in and out of the hospital setting, including troubling implications for children with chronic and congenital diseases that are not easily cured, or conditions such as deafness and autism whose disease status is contested. Particularly disturbing is the implication that children who die have been defeated—they have lost the battle. More subtle issues involve the implicit imposition of a soldier’s virtues: obedience, silence, self-sacrifice. But we will also expand our study beyond the myopia around military language in medical ethics to discuss how other common and potentially harmful illness storylines, like that of illness as journey, may stem from and reinforce mistaken cultural notions of what it means to be a child. At the same time, we will reject recent arguments in medical ethics that metaphors are inherently harmful and should be abandoned in favor of literal language. As described above, this fundamentally misunderstands the way that human language works. In fact, it is the cultural priority of literal language that often silences children’s insights.
Our analysis will pay special attention to the voices of children. This means we will assess the ways canonicity can silence them, and argue for making space for the metaphorical rupture that children bring. Stale canonical frameworks are changed through metaphorical ruptures that bring new meaning, something children excel at through their play with language, nonsense, and story. The linguistic repertoires of younger children, though less rich than those of adults, are perhaps more fertile, since they are unbound by the constraints of convention. Our study will also rely on a specifically Christian understanding of what it means to be a child. Children are already in relationship to God and others, and childhood is not something we leave behind, but continues to shape us: the language that forms our selfhood in childhood endures. This affirms the importance of using the right language with children, particularly in the immediacy of pediatric settings. But children can also teach us about the possibilities of story and metaphor, where their linguistic play brings new meanings beyond the concrete investigations of medical knowledge to make space for hope, for human and divine encounter.
Thus, we will argue that metaphor use is crucial to human language, and to clear communication in the pediatric setting. But because these metaphors shape our very selves, we must constantly evaluate particular metaphor use, perceiving the ways canonical language can shape us, and opening ourselves to the metaphorical ruptures possible in every human encounter. We must constantly evaluate whether our metaphor use reflects the reality of who children are in God. Finally, we will offer guidelines for metaphor use in pediatric medicine based on a practical, narrative-focused, framework—a framework that understands metaphor as co-created between patients, families, and clinicians, open to change and conversation, integral to communication, and constitutive of selfhood and reality.
This lack of focus is a mistake. It stems from a deformed style of reasoning which treats anything that is not physical as though it were unreal. But language is very real. As Hans- Georg Gadamer noted, “You must realize that when you take a word in your mouth, you have not taken up some arbitrary tool which can be thrown in a corner if it doesn’t do the job, but you are committed to a line of thought that comes from afar and reaches on beyond you.” (1982, pp. 547–548)
Language not only conveys information, but also shapes our perspectives, our experiences, and our very selves. This is especially true of metaphor. For example, when Christian believers call God a father, a shepherd, or a lion, the metaphor itself contributes to their mode of worship and understanding of self in relationship to the divine. Language, particularly metaphor, constitutes social reality. Thinking deeply about the language we use is thus crucial to medical ethics, especially in the realm of pediatrics, where children are being formed and forming their selfhood for the first time.
There are limited studies examining the uses of metaphor in medical discourse. However, existing studies suggest that patients’ behavior and lived experience of illness are partly determined by the choice of metaphor used in clinical communication. For instance, some recent work has highlighted a link between anxiety and the use of war metaphors among cancer patients. Other studies suggest a link between particular metaphorical descriptions of cancer, and patients' likelihood of adopting preventive behaviors. Yet many of these studies are hamstrung by a reliance on crude and underdeveloped accounts of language. They make the mistake of assuming that metaphor is an aberration of linguistic form, standing opposed to “pure,” “simple,” or “literal” language. On this basis, they make universal pronouncements on acceptable metaphors, failing to understand the contextual and relational nature of language use. Consequently, insofar as many studies fail to account for the rich and ever- evolving ways that metaphors build and constitute human social reality, they are limited in impact and scope.
Our interdisciplinary panel—composed of a linguist, a physician-ethicist, and theological ethicist—will examine the use of metaphor in pediatric medicine, with its complex matrix of relational voices, and consider the ways that children receive, use, and co-construct metaphoric structures. We focus on pediatrics for two reasons. First, there is little scholarship on pediatric metaphor use. Second, children are uniquely susceptible to the power of language to construct self-understanding and social identity. We will begin by identifying the explicit and implicit definitions of ‘metaphor’ employed in the medical ethics literature. In doing so, we will challenge the prevalent conception of metaphoric language as the antithesis of literal language, instead revisioning metaphoricity as the antidote to canonicity—the quality of having entrenched, conventionalized meaning within a given discourse community. The imperfect mapping between subjective experience and canonical language leaves space for what we call metaphorical ruptures, tears in the discursive fabric through which raw meanings can emerge. Metaphoric language is, on this view, not that whose meaning diverges from its truer or more literal semantic denotation, but that by which the lived experiences of social actors are transferred to unconventional but interpretable linguistic forms. In view of this revisioning, we will draw from the toolkit of linguistic discourse analysis—specifically, the concepts of framing and positioning—to examine publicly available video excerpts of communication with and around chronically ill children. Our analysis will highlight the ways that metaphoric structures are locally deployed and negotiated in interactive frames while illustrating how participants in pediatric relationships use canonical language to position subjects within the cultural storylines of illness and treatment at play in the broader discourse community.
This framework for understanding metaphorical language within clinical encounters will set the stage for an ethical evaluation of particular canonical storylines used in pediatric care. Military language dominates the cultural discourses surrounding pediatrics, from advertisements that declare “sick isn’t weak; sick fights back” to assertions that “my child is a fighter.” We will discuss the potential harms this dominance causes, both in and out of the hospital setting, including troubling implications for children with chronic and congenital diseases that are not easily cured, or conditions such as deafness and autism whose disease status is contested. Particularly disturbing is the implication that children who die have been defeated—they have lost the battle. More subtle issues involve the implicit imposition of a soldier’s virtues: obedience, silence, self-sacrifice. But we will also expand our study beyond the myopia around military language in medical ethics to discuss how other common and potentially harmful illness storylines, like that of illness as journey, may stem from and reinforce mistaken cultural notions of what it means to be a child. At the same time, we will reject recent arguments in medical ethics that metaphors are inherently harmful and should be abandoned in favor of literal language. As described above, this fundamentally misunderstands the way that human language works. In fact, it is the cultural priority of literal language that often silences children’s insights.
Our analysis will pay special attention to the voices of children. This means we will assess the ways canonicity can silence them, and argue for making space for the metaphorical rupture that children bring. Stale canonical frameworks are changed through metaphorical ruptures that bring new meaning, something children excel at through their play with language, nonsense, and story. The linguistic repertoires of younger children, though less rich than those of adults, are perhaps more fertile, since they are unbound by the constraints of convention. Our study will also rely on a specifically Christian understanding of what it means to be a child. Children are already in relationship to God and others, and childhood is not something we leave behind, but continues to shape us: the language that forms our selfhood in childhood endures. This affirms the importance of using the right language with children, particularly in the immediacy of pediatric settings. But children can also teach us about the possibilities of story and metaphor, where their linguistic play brings new meanings beyond the concrete investigations of medical knowledge to make space for hope, for human and divine encounter.
Thus, we will argue that metaphor use is crucial to human language, and to clear communication in the pediatric setting. But because these metaphors shape our very selves, we must constantly evaluate particular metaphor use, perceiving the ways canonical language can shape us, and opening ourselves to the metaphorical ruptures possible in every human encounter. We must constantly evaluate whether our metaphor use reflects the reality of who children are in God. Finally, we will offer guidelines for metaphor use in pediatric medicine based on a practical, narrative-focused, framework—a framework that understands metaphor as co-created between patients, families, and clinicians, open to change and conversation, integral to communication, and constitutive of selfhood and reality.