The Handbook of Discourse Analysis

486 Suzanne Fleischman
The conceptual macrometaphor suggests that we place our bodies in a custodial
relationship to the medical establishment analogous to the relationship of our vehicles,
for example, to the confraternity of auto mechanics to whom we turn for repairs
or replacement parts (on the “fix-it” metaphor, see Kirkmayer 1988; Carter 1989).
Doctors and patients alike may find objectionable, because dehumanizing, the image
of physicians who work as mechanics or technicians and of illness sufferers metonymically
reduced to a malfunctioning body part (see section 4.3). Warner (1976) goes so far
as to suggest that the power of this metaphor might contribute to an overuse of
surgical procedures.
Another prominent set of metaphors in medicine are those of “marketplace economics.”
These metaphors inform our language about diseases (TB, cancer, and now
AIDS), and with the current emphasis in America on “managed care,” health care
itself. Sontag (1978) points out that the fantasies about TB that arose in the nineteenth
century (and continued into the twentieth) echo the attitudes of early capitalist accumulation:
one has a limited amount of energy, which must be properly spent. Energy,
like savings, can be depleted, run out, or be used up through reckless expenditure. The
body will start “consuming” itself, the patient will “waste away” (1990: 62; see also
Rothman 1994). Mutatis mutandis, this network of metaphors has migrated into the
thinking/discourse about AIDS. And if TB was conceptualized via images that sum the
negative economic behavior of nineteenth-century Homo economicus – consumption,
wasting, squandering of vitality – then cancer is conceptualized through images that
sum up the negative behavior of twentieth-century Homo economicus – unregulated,
abnormal growth, repression of energy (refusal to consume or spend) (Sontag 1990: 63).
Health care in America today is more than ever before a matter of economics.
Discussions of treatment, procedures, drugs, and hospitalization are suffused with
marketplace concepts and vocabulary, which have clearly influenced our thinking
about the treatment of illness. Particularly since the rise of the carefully controlled
biomedical economy referred to as “managed care,” commodification has become a
reality and not simply a way of thinking and speaking. “Health care is a commodity”:
treatments are “sold” by physicians and hospitals and “bought” by patients (the
euphemism “health-care consumers” proliferates in policy statements and media discourse),
and physicians are employees of medical “businesses.” Optimal “delivery” of
health care is “calculated” according to a balance sheet, notably by the “bottom line”
(cf. Fein 1982; Diekema 1989). Medical education, too, is increasingly subject to the “law
of supply and demand,” notably as regards the training of physicians in subspecialties.
Other conceptual metaphors of medicine have been or will be dealt with in other
sections of this chapter: “the patient as text” (section 3), “disease as an object” and
its corollary “the patient as container” (section 5.1), and spatial metaphors, notably
“causation (etiology) as a line” (section 4.5). A leitmotif running throughout Hunter’s
Doctors’ Stories (1991) is the metaphor of “medicine as a detective story” (cf. also
Hodgkin 1985).
4.3 The body and its metaphors
As linguists, anthropologists, and cultural investigators of the body have long recognized,
in virtually every language and every culture body parts serve as metaphors.