Gerald R. Winslow, PhD, Dean, Faculty of Religion, Chair, Center for Christian Bioethics, Loma Linda University
Jack W. Provonsha Lectureship
School of Medicine Alumni Postgraduate Convention
Loma Linda University
March 5, 1994
We should watch the way we talk. Human society can be described as a long conversation about what matters. In this conversation, the language we use to describe our social practices not only reveals our values and virtues, it shapes them. Nowhere is this more evident than in the language of health care.
I want to consider four ways of talking about health care and ask about their ethical significance. By paying more attention to the way language captivates our moral imaginations, we may be better able to use language that comports with, rather than corrupts, our moral convictions. In the process of minding the language of health care, we should pay special attention to the resources provided by health care's roots in religion as a way of preserving some of health care's most important values.
Anyone who knows more than one language knows how difficult it is to express oneself when the words are missing. I once met an English-speaking pastor whose Alberta congregation included a number of German immigrants. At a social occasion, he reported, hearty laughter resulted from a joke told in German. When the pastor asked what was funny, the joke teller started to repeat the joke in English. He then hesitated and said, "'Tain't funny in English!"
The problem is not always just cleverness in translation. The requisite conceptual categories may be absent if the language is missing the needed words. In short, sometimes words really do fail us.
Within the system of any language, it is the usage of words that determines their meanings. Words have no absolute definitions determined by some celestial lexicographer. They mean what they do when interacting with each other.
Let me illustrate. When my family and I first lived in Austria, my older daughter, then four, began playing with the other children in the park. But there was confusion, rejection, and even a few tears. She couldn't communicate in German, and insisted that she would never be able to learn how. After only a couple of weeks, however, I observed her one day on the merry-go-round. As she rode, she was shouting to the other children "Schneller! Schneller, bitte!" Later, walking home, I said to her, "I see that you've learned some German." "No," she answered, "I haven't." "But I heard you say 'schneller, bitte' on the merry-go-round," I said. "What does that mean?" She looked puzzled and answered, as only a four-year-old could, "I don't know, Daddy, but it makes the merry-go-round go faster."
As my daughter discovered, words are powerful tools. They can signal our intentions or desires. They can convey our sense of values. And, once established, they also form our understanding of what is real, what is possible, and what is valuable. As individuals, we get to contribute very few words to our languages. (I doubt that I have added any.) Rather, the powerful tools of language are a gift to us from social inter-action in a culture. Individuals quickly come and go. The language remains, and changes rather slowly, exercising its power for many generations.
Among the most powerful tools in language are the figures of speech we call metaphors. They are also among the most difficult to explain in straightforward speech. Consider the difficulty of clarifying for my visiting German cousins sentences such as: "Jim is a square." Or, "In the presence of dogs, most cats are chicken." Even the most thorough dictionary knowledge of the language will not help to make sense of these utterances. Still, it is likely that most native speakers of American English will have little trouble getting the meaning.
Metaphors function by suggesting some resemblance or analogy between two things or experiences that are not literally the same. Metaphors are not, however, mere rhetorical flourishes or linguistic decorations. Rather, they are potent instruments for empowering conceptualization.1
The power of metaphors to enliven and shape our moral imagination can be illustrated by examples from health care: "The patient in room 213 is a vegetable." "A fetus is the most common tumor of the uterus." I have heard expressions like these--the first quite often, the second only once. Whether used frequently or seldom, they have common elements. In each case, the metaphor expresses an analogy that highlights some features of reality while obscuring or distorting many others (a point to which I will return later).
When we hear that the patient is a vegetable, no sensible (or sensitive) person would ask, "What sort of vegetable?" Nor would we be permitted to do to the patient what we typically do to vegetables. We know, or are supposed to know, that the expression does not refer to the patient's skin color or texture but rather refers to the patient's decerebrate state. Calling a patient a "vegetable" fixes this fact in our minds in an indelible way.
But, having disclosed this aspect of reality, the metaphor also obscures a great deal. In most every respect, the patient is not really at all like a vegetable. The first time in the history of language that a patient was called a vegetable we may imagine that the expression was surprising and maybe even disturbing. But it has now become so common that it occasions little or no shock. The metaphor has even worked its way into the official language of health care professionals: the "persistent vegetative state."
The second example, the fetus as tumor, is not common. It is jarring. If it were to work its way into ordinary parlance, it would say much about how to evaluate fetal life. If it were to become completely common, it would also develop considerable power to construct the way we, or subsequent initiates in our language, think about prenatal life.
It is this interaction between language and ethics that I want to explore with four examples from the history of health care. At different times, these have become conventional, metaphorical systems in the everyday language of health care. They are not just single metaphors, but rather systems in which a number of complementary metaphors work synergistically both to describe and preserve distinct meanings of health care. Moreover, such systems, with their interlocking metaphors, are not easily translated into non-figurative speech. Indeed, it is doubtful that such translation is even possible without significant loss of meaning. These examples will illustrate why it is important to mind our language.
The Ministry of Healing
Probably the oldest way to represent health care in Western culture (and maybe in most human societies) is as religious service. The Oath of Hippocrates, for example, begins with sworn allegiance to the gods: "I swear by Apollo Physician and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant."
The idea of health care as sacred service was strong not only in ancient Greek culture, but also in the Judeo-Christian tradition. One of the most beautiful expressions of health care as a divinely appointed ministry is the prayer attributed to the famous medieval Jewish physician, Maimonides. It ends with these words:
Thou, All-Bountiful One, hast chosen me to watch over the life and death of Thy creatures. I prepare myself now for my calling. Stand Thou by me in this great task, so that it may prosper. For without Thine aid man prospers not even in the smallest things.2
For centuries, the linkage between religious faith and health care was strong in the Christian community. In the Christian testament, one word (sozo) means both "to heal" and "to save." The healing and saving ministry of Jesus served as the model for Christians.
Early Christians are known to have established a variety of facilities for the sick and the poor. As early as 330 A.D., St. Helena, mother of Constantine, established a hospital as an act of Christian service. When, late in the fourth century, Emperor Julian the Apostate attempted to return the realm to pagan religion, he blamed Christian hospitals and the women who served in them for Christianity's hold on the common people, and proposed establishing pagan alternatives as an antidote.
By the time of the crusades, most organized health care was delivered by religious orders such as the Order of the Knights of the Hospital of St. John of Jerusalem (or Hospitalers), the Order of the Knights of the Temple of Solomon (or Templars), and the Order of Lazarus, which was devoted to the care of lepers. One of these religious orders, San Spirito (or Order of the Holy Ghost), founded hospitals first in Rome and then in nearly all major European cities.
The language of ministry is also found in more recent works on medical ethics. For example, Percival's book, which held sway in England and America for well over a century, is full of such language. He wrote: "Hospital physicians and surgeons should minister to the sick...."3 He also suggested that sickness could function to bring people to an openness to religious influence. Physicians should be aware of this opportunity and should also support the work of the clergy in their ministry to the sick. Percival even went so far as to insist that hospital rounds and consultations should be scheduled in such way as not to interfere with religious services.4
Other evidence of Western health care's roots in religious faith remain throughout modern cultures, including their languages. In Germany, for example, nurses are still called "krankenschwestern," or sisters for the sick. In England, head nurses are still referred to as "ward sisters." Students at Loma Linda University once graduated from the College of Medical Evangelists. Hospitals named for saints or called Sacred Heart or Good Samaritan are still common. I even see ambulances named "Mercy." Christian denominations, including Roman Catholics, Lutherans, and Adventists own and operate health care facilities throughout the world. Countless thousands of health care professionals worldwide understand their work first of all as serving God by caring for those in need.
The language of health care as a ministry is the language of service, compassion, and covenant loyalty. It is the language of work in a sacred calling. For Christians, it is an extension of the healing ministry of Jesus. Such language is made explicit in the mission statement of our host institution: "The mission of Loma Linda University is to further the healing and teach-
War Against Disease
During the second half of the last century a new way of talking about health care arose. Medicine became a war against disease. Susan Sontag suggests that the change in language occurred in part because of the rise of the germ theory.5 It is also the case that much of what medicine learned in areas such as trauma surgery and triage was learned on the battlefield. Whatever its source, and however novel it may first have seemed, the metaphor of health care as a battle became commonplace.
In this way of speaking, disease is the enemy which threatens to invade the body and overwhelm its defenses. Medicine combats disease with batteries of tests and arsenals of drugs. As physicians battle illness, they sometimes refer to their armamentarium. They also write orders. Young staff physicians are still called house officers. Nurses, who take orders, also work at stations. In the past, at least, they also wore uniforms while on duty. But as one early author on nursing decorum wrote, nurses should not wear uniforms when off duty; then, they should wear "civilian dress."6 As nurses progressed up the ranks, stripes were added to their caps, and insignia pins to their uniforms. Sometimes their orders even called for them to give shots.
The language of military discipline pervaded much of the literature of nursing and medicine early in this century. One nursing leader wrote: "Carrying out the military idea, there are ranks in authority....The military command is couched in no uncertain terms. Clear, explicit directions are given, and are received with unquestioning obedience."7
The language of medicine as war lives on in many obvious ways. It is still common for politicians to win popular support by calling for a war on some disease such as cancer or AIDS. And in a recent article on medical residencies, the author writes "[H]ouse officers often relieve the stress of physicians who have completed their training by manning the front lines of acute medical care...."8
Health care's military language speaks of loyal obedience to authority, and courageous service against a common enemy. To the extent that this language retains its power, it supports a willingness to accept danger, work long hours, and suffer hardships for the sake of winning the struggle against illness.
Defense of Patients' Rights
In the 1960s and 1970s, another way of talking about health care arose with the patients' rights movement. Sociologist Paul Starr has detailed what he calls the "stunning loss of confidence" sustained by health care professionals in the 1970s. Previously, the "sovereign profession" of medicine was largely unchallenged in its authority. But with the rise of consumerism, health care was increasingly depicted as an arrogant and impersonal bureaucracy from which patients, now called clients, deserved protection.
The new metaphorical system drew heavily on legal terminology and traditions. For example, patients would now be protected by "A Patient's Bill of Rights," authored principally, it might be noted, by an attorney and adopted by the American Hospital Association (AHA) in 1973. In its preface to this document, the AHA states: "The traditional physician-patient relationship takes on a new dimension when care is rendered within an organizational structure. Legal precedent has established that the institution itself also has a responsibility to the patient."9 The document reassures patients that they have numerous rights, including the right to full information about their diagnosis, prognosis, and proposed treatments, the right to consent to care, the right to refuse unwanted care, and the right to confidentiality.
The legal nature of this way of speaking was furthered by the language of patient advocacy. Health care professionals, especially nurses, adopted the role of being client advocates.10 We have only to recall that another profession has clients and refers to its practitioners as advocates to see the legal linkage. Now, instead of being servants of God in the ministry of healing or good soldiers in the war against disease, these new advocates courageously defended the rights of their clients against the overbearing paternalism of earlier tradition. Within this newer metaphoric system, what needs protection, as much as the patient's health, are the patient's rights, especially the right to personal autonomy, as guarded by the practice of informed consent.
The 1970s also saw a dramatic increase in the practice of suing health care professionals, especially physicians, on the grounds that they had failed to honor patient's rights to adequately informed consent. In California, for example, the landmark case of Cobbs v. Grant established that a surgeon could be sued successfully not because he was negligent but because "he did not discuss any of the inherent risks of the surgery" with the patient.11
The legal approach to health care, with its attendant language, is also revealed in the rise of the so-called "advanced directives." Borrowing again from the law, patients were given the options of preparing "living wills" or assigning "durable power of attorney for health care." California led the way with both of these approaches, enacting the "Natural Death Act," with its "Directive to Physicians" (our state's version of the living will) in 1976 and establishing durable power of attorney specifically for health care in 1983.
Thus, the language that accompanies the defense of patients' rights is a metaphorical system borrowed largely from the law. It emphasizes patient dignity and condemns paternalism. It calls for health care institutions and the professionals who work in them to protect the rights of their clients against any offenders.
Health Care Industry
The latest contender for metaphorical dominance comes not from the law but from corporate America.
It is the language of the health care industry.
The first person, of whom I am aware, who noticed this new candidate for linguistic dominance was Rashi Fein. He did not like what he was hearing. In a short 1982 article in the New England Journal of Medicine, Fein complained: "A new language is infecting the culture of American medicine. It is the language of the marketplace...and of the cost accountant."12 Fein went on to say that such language is dangerous because it "depersonalizes both patients and physicians."
Despite such protests, the language of the health care industry now bids fair to dominate the way we speak of health care. Despite his rather prescient observations, Rashi Fein could hardly have imagined over a decade ago just how pervasive such language would become. It is now so common that one probably runs the risk of sounding like a crank, or worse, for even bothering to notice it. This is the age of managed care, or what some call managed competition. Consider the following now ordinary expressions, all taken from one article on health care management:13 "Total quality management" is a system intended to "reduce costs" while maintaining quality in "a highly competitive market." Today's health care must "identify its customers" and understand the "business connotation of customer-supplier." "Competitive advantage improves as a result of improved quality and lower costs."
With increasing frequency, one now hears hospitals refer to their "product line," their "market share," their "human resources," and even their "guests." The industry is increasingly "customer driven," "cost conscious," and "productivity" oriented. Treatments are more and more evaluated for their "costworthiness" by using complicated "cost-benefit ratios." Health care professionals are now "providers" who give their customers (or guests, or consumers) what the customers want and at the lowest possible price. One highly revealing sentence in a recent edition of the journal Medical Economics says it all: "In management you'll have to switch your concern from the well-being of the patient to the health of the bottom line."14
The language of the health care industry is borrowed from economics and from the ethos of business, especially big business. It has the feel of hard-edged realism. Old-fashioned solo entrepreneurs had better get in line. Health care is a competitive business in which the big powers typically triumph over their smaller competitors. The language of industry makes it seem normal to attend to marketing, competition, and customer satisfaction.
Metaphors and Moral Values. How do metaphoric systems, like the four just mentioned, interact with our moral values, judgments, and actions? I want to suggest four features that deserve our attention.
1. Metaphors are powerful partly because of their capacity to highlight certain aspects of reality in memorable ways while obscuring other aspects of reality.
We do well to pay attention not only to what the metaphorical systems, which I have outlined, disclose, but also what they may obscure or distort. To call health care a ministry is to emphasize faithful service, devotion, and compassion. In all honesty, however, we must also say that the language of the ministry of healing has sometimes obscured the fact that such care requires a sound scientific basis and has to be paid for in some way. Even the most charitable ministries of healing were also economic realities. Failure to notice the fact that ministers of healing must also be adequately compensated for their services could easily lead to the exploitation of some health care professionals. Ministering beneficently to the needs of others may also lead to attitudes and actions of paternalism, in which the patient's own preferences are given little heed.
Similarly, health care as war highlights the struggle against a common enemy. This metaphor can awaken courage and a willingness to sacrifice for a good cause. But the metaphor can (indeed, has) work very effectively to preserve patterns of authoritarian relationships, with unquestioning obedience and loyalty that few would find healthy today.
The legal metaphor of patients' rights focuses on the inviolability of each person. But an overemphasis on honoring rights may obscure patients' responsibilities for their own health. The legal language may also distort the reality of intimate human relationships within families and between families and their professional caregivers.
The industrial metaphor reminds us that health care is, and always has been, an economic enterprise. Still, an emphasis on competitive advantage in seeking customers for health care products may obscure or miserably distort the virtues necessary to care genuinely for sick people.
2. Metaphorical systems make some actions seem normal and expected, while making other actions seem strange or unacceptable.
Once established, a way of speaking about health care can affect attitudes which, in turn, will affect behavior. If, for example, the military metaphor is dominant, "normal" actions would include obeying orders, respecting one's superiors, wearing uniforms, taking risks (including the risk of death), feeling and being loyal, and suffering hardships such as night duty and low pay. At the same time, other actions would seem strangely unacceptable: questioning orders or disobeying them, refusing to accept risks, sharing secrets, and demanding higher pay.
While they are dominant, metaphorical systems often work their way into the structure of social institutions at both formal and informal levels. It is not uncommon for such metaphors even to become part of social policy and law. The legal metaphor of being a patient advocate was once a novel idea. Now it is part of California's law. The state's Nurse Practice Act now includes in the list of standards of competence the following:
A registered nurse shall be considered competent when he/she...acts as the client's advocate, as circumstances require, by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the opportunity to make informed decisions about health care before it is provided.
One fine institution, Sarah Lawrence University, even offers a master's degree in "Health Advocacy." And Index Medicus now lists "patient advocacy" as a separate category. A computer search of one recent year's entries indicated that there were 167 articles under this heading--not bad for a locution that was new-fangled just two decades earlier.
3. Metaphorical systems become most powerful when their usage is least noticed.
The power of such language to focus our attention and grab our imagination grows as it becomes time-worn. This is so because the ability to highlight some aspects of reality, while obscuring others, becomes greater when common usage has caused the metaphorical nature of the language to be lost from view. It is just when such language becomes unremarkable that it has the power to make some character traits appear virtuous and some vicious, some actions normal and expected and other simply strange. So, for example, the jargon of the health care industry, which occasioned the ire of Rashi Fein a dozen years ago, is now so common that it goes almost entirely unnoticed. To attend the hospital's marketing committee and discuss its product line or market share is now normal. It would require a tenacious memory to recall the time when such language was new.
4. Metaphorical systems are dominant only for a time.
In time, they fade and find their hegemony displaced by a new system that has slipped into our ordinary speech, generally unannounced. Rarely, if ever, are metaphorical systems destroyed by design, because critics found them unworthy. Nor is it that the older ways of speaking grow too trite. They just cease to be effective. They fade into the background of usage, gradually becoming impotent or unheard. Such metaphorical systems, just like many Native American languages, become lost, sometimes irretrievably. In this regard, language is like a giant attic with discarded items from an earlier time gathering dust, largely, if not entirely, forgotten. So, today, one does not hear much about the ministry of healing. Don't look for it in Index Medicus. Perhaps, even now, we may imagine some scholar with a grant from the National Endowment for the Humanities going around with a tape recorder looking for health care professionals whose mother tongue was the language of ministry, and who can still remember a few phrases.
It is a long way from the ministry of healing to the health care industry. The distance is not best measured in miles or even years. It is most accurately measured as the distance between the sets of values and virtues that these ways of speaking represent and inform. It is the distance between a world filled with spiritual realties and one that is radically secularized.
It is, of course, still possible in our culture to pull the language of ministry out of the attic, dust it off, and use it again. Despite what our high school composition teachers taught us, metaphors can even be mixed. Consider the expression, "No margin, no mission." I have sometimes heard this around health care institutions with a religious heritage. But within the context of a pluralistic, secular culture, we should expect to hear such language ever less frequently.
Does this mean that the language of the ministry of healing is lost? If so, is the loss irretrievable? And if that is so, should we mourn the passing? Or should we simply long nostalgically for an earlier time?
My answer is that remembering and reasserting the language of ministry is part of the special mission of institutions like Loma Linda University. It is, of course, not the language itself that is finally important. It is the spiritual reality to which the language bears witness that matters. The special contribution of communities of memory, like this one, includes the preservation of the forms of expression that remind us of ultimate, spiritual truths. People of faith have a distinctive task in this regard. They cannot expect others to do this job for them. Nor should we imagine that adhering to this mission is easy. To understand this, we have only to think again of all the native languages that have become extinct in our society, even when heroic measures were taken to preserve them. Completely embedded in a culture where the language of the market dominates, it will be increasingly difficult to remember or to teach our children that health care for us is first of all a spiritual calling.
In order to understand the importance of what is at stake, we have merely to consider what would be lost if the industrial metaphor becomes the only language used to describe the meaning of health care. If the language of the bottom line must be spoken, and sometimes it must, then special care should be taken, by those who can, to speak often the language of ministry. Whatever the metaphor currently in vogue, the fundamental task of health care requires sincere concern in the face of illness and eventual death. The language of ministry supported such concern in a powerful manner, and the retrieval and preservation of such language, however difficult, is not impossible. And it is worth the trouble.
I conclude with a story that, I trust, will explain itself. Not long ago two of my favorite uncles, whose first language was German, came from the Midwest to visit my mother in Oregon. I made a special trip there to see them again and to videotape these octogenarians as they told stories from the past. After a while, I suggested that we use the speaker phone to call one of our cousins in Germany, one about their same age. I read embarrassment on both of their faces. Then, with reticence, they explained that they had not spoken German in many years and there was no way they could carry on a conversation. Never mind, I said, I would translate for them. I made the call. Then something interesting happened. About one minute into the conversation, first one and then the other uncle began to join the conversation without my help. The pace picked up. A certain joy was obvious, and I was, for the most part, sidelined as three cousins swapped stories in a language that two of them were sure had been lost. Finally, I had to suggest that it was time to say "aufwiederhoren."