Metaphors matter: from biobank to a library of medical information

The concept of the biobank is central to large-scale biomedical research enterprises such as the All of Us Research Program (https://allofus.nih.gov/). The term biobank has become commonplace as a signifier for the collection and storage of human biological samples for future research use but the fact that it is metaphorical is not given much attention. Biobank utilizes the familiar concept of a financial institution, and also has historical associations with the terms blood bank, tissue bank, and organ bank. We argue that, because metaphors such as biobank can influence public attitudes and interpretation of complex scientific concepts, yet have culturally specific meanings,1 the choice of metaphorical terms requires careful consideration to engender trust, especially among populations underrepresented in biobank-related research.

Biobank-based research is complex and likely to be unfamiliar to many people, so the biobank metaphor can be a valuable communication tool because it links an abstract, unfamiliar concept to a concrete, familiar experience.2 For example, the concept of randomization has commonly been described as a toss of a coin. However, metaphors have been widely subjected to conceptual and normative critique for their potential to mislead, to the extent that they highlight some characteristics of the target domain while downplaying others.2 Because metaphors are inevitably selective, choosing any specific metaphor is a rhetorical act with normative implications, even for scientists.3

Conceptual critiques of the biobanking metaphor include arguments that the transactional nature of the commercial aspect of banking emphasizes value and exchange of tangible materials at the expense of privacy concerns by downplaying the informational nature of biobank-based research.4 Furthermore, the implied linkage of biobanking to blood banking and organ banking has been deemed problematic for drawing attention to the benefits of donation while failing to acknowledge commercial interests.4,5 For example, in the United Kingdom’s proposals for a national biobank, the UK government and several nongovernmental organizations may have capitalized on the sense of altruism and community benefit associated with hospitals and blood banks by using images of blood donation as a gift to strangers.5

Discourse that uses the biobank metaphor trades in particular values. However, it is an open question whether the metaphor affects public attitudes and behavior adversely, especially in culturally diverse populations whose inclusion in biobanks is critically important.6 Research suggests that metaphors affect how concepts are understood,2 and can influence behavior of both insiders and the general public.7,8 For example, studies comparing descriptions of the flu literally (as a virus) versus metaphorically (as a beast, riot, army, or weed) found that more individuals who received the metaphorical descriptions were willing to get vaccinated.9 Additionally, the meanings and connotations of metaphors assumed by scientists or journalists are not always shared by the general public. For example, the assumption that the blueprint metaphor for DNA would be more deterministic than recipe was not supported by empirical study.10

In the course of developing informational trigger videos about biobank research for focus group studies of attitudes toward biobank-based research (http://thevaluesproject.stanford.edu/), we learned valuable lessons about how people from diverse cultural backgrounds (including native English, Spanish, and Mandarin speakers, who we engaged in these languages) perceive related metaphors. When we asked patients to tell us what the word biobank made them think of, they offered a number of different terms that emphasized different attributes of biobanks. These terms included financial bank, gold mine, organ or blood bank, cryobank, database, and large computer, which vary in how well they represent or emphasize important concepts of a modern biobank (conceptual accuracy); the terms also vary in whether and to what degree they carry positive or negative associations (valence). (See Table 1.) While financial bank and organ or blood bank both utilize the bank metaphor, they generated different reactions that suggested that the concept of a tissue bank has lost its figurative quality through sustained use.

Table 1 Conceptual accuracy and valence of patient-generated terms

The apparent drawbacks to various patient-generated terms, especially the strong negative reaction to the commercial connotations of financial bank or gold mine, suggested that a search for a more appropriate metaphor was warranted.3 Biobank may well be another example of how actual perceptions of a metaphor do not necessarily reflect theoretical or intended meanings.10 Although the analogies to financial banking and blood banking have been criticized for overemphasizing positive values of benefit and altruism in theory, actual patients assigned a negative valence to the biobank metaphor, spontaneously making links to the use of health information for financial gain, in the course of either drug development or health insurance provision.

We considered various alternatives, and selected pool or reservoir, and library as the most promising. (See Figure 1.) While we recognized that no metaphor would be fully representative, we chose to use the library metaphor in our informational videos because we believed it captured more of the key characteristics than a pool or reservoir for the purposes of describing a research biobank. It was also amenable to visual representation; we used images of a building, labeled Library of Medical Information, to represent a biobank.

Figure 1
figure1

Alternatives to the biobank metaphor and their strengths.

The library metaphor was advantageous for several reasons. First, it allowed us to represent the concept of electronic data or biosamples donated by human individuals in the form of file folders or test tubes that were stored on shelves. In contrast, the pool metaphor did not allow depiction of a collection of discrete items of different types, because its contents (e.g., water) become homogeneous and indistinguishable once deposited.

Second, we could address concerns about security that had been expressed by patients by highlighting differences between “your public library,” which is open to the public, and a Library of Medical Information, which has security to protect information and a gatekeeper to control access by legitimate users only. (See Figure 2.)

Figure 2
figure2

Visual metaphor of the library: security.

Third, the concept and images could be used to emphasize the key feature of information sharing. For example, some images showed interconnections between several similar but nonidentical libraries to illustrate how information might be networked and transferred. (See Figure 3.)

Figure 3
figure3

Visual metaphor of the library: networking and data sharing.

Fourth, library was familiar and also potentially minimized misunderstandings. Patients noted that libraries are widely recognized as a place for research and an important part of the community. Moreover, it allowed representation as a resource built by public support, without placing strong emphasis on the individual altruistic aspects of research participation represented by gift-based metaphors; it also allowed us to address a commonly expressed misconception, i.e., that a patient’s contributed data and samples would be used directly by physicians to inform and benefit the same patient’s health care, by disconnecting ownership and research uses from downstream findings and clinical applications. In contrast, banking suggests a more direct, and potentially misleading, relationship between contribution and benefits.4

However, patients also noted some possible drawbacks to the library metaphor: for example, that young people might not be as familiar with libraries. Moreover, to some the idea of depicting the data as physical books rather than as electronic or computerized texts seemed outdated or overly simplistic. But others pointed out that some people do not use computers and the book analogy is universally understood.

Some patients commented that books are less likely than electronic data to raise the issue of tampering or stealing, which was, interestingly, a potential weakness also identified about the banking metaphor to the extent that it downplays security risks. To convey this risk, we used images of a thief drilling into a vault, and to depict security we used images of the library being protected by a vault-like structure (ironically, making the library more like a bank). We illustrated control of access to the Library of Medical Information with a librarian behind a counter overseeing who could enter the library and check out the books.

We encountered specific challenges to using metaphors when translating the videos from English to other languages, especially to Mandarin Chinese, which uses a logographic writing system and in which written text may not represent typical spoken dialogue. For example, in Mandarin, the literal translation of library in Chinese characters () is a combination of the characters representing book () and physical place or stadium (). However, when asked “What is the Library of Medical Information?” most Chinese patients would say database in either Mandarin or English. However, using database might have changed the perception of the function, risk, and benefit of the Library of Medical Information, or even caused or exacerbated misconceptions. For example, in a focus group of Chinese patients, one said that a benefit of the database was that a patient could directly look up information in it, obviating the need to see a doctor.

There is probably no perfect metaphoric vehicle to represent the “biobanking” aspect of large-scale biomedical research enterprises such as the All of Us Research Program. The ideal term would capture all important factors, be unbiased normatively, and convey equivalent meanings across culturally diverse populations. However, because biobank is so commonly used in public communication about biomedical research, including in recruitment and consent materials, it is particularly important to understand the actual impact of the term and to consider and evaluate alternatives.

The lessons we learned support the proposal that researchers should assess the appropriateness of metaphors for science communication, through interdisciplinary collaboration that includes expertise from biology, medicine, social sciences, and the humanities.3 Additionally, through empirical study we can better understand how potential research participants and the broader public perceive and react to commonly used metaphors and alternatives, and in turn how the use of those metaphors might affect the success of clinical and translational research.

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Acknowledgments

This project was supported by a grant from the National Institutes of Health/National Library of Medicine (1R01LM012180-01). We gratefully acknowledge the contributions of our colleagues from the Palo Alto Medical Foundation Research Institute: Meghan Halley for her work in developing the focus groups and videos, and analysis; Lu Wah Hung and Yasmin Hernandez for translation of videos, focus group materials, and data to and from Mandarin and Spanish, respectively, and for leading focus groups; and Harold S. Luft for valuable input on instrument and study design. This study was approved by the institutional review boards of Stanford University and the Palo Alto Medical Foundation Research Institute, with the informed consent of research participants.

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Correspondence to Mildred K Cho PhD.

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G.A. and A.T. are cofounders of Booster Shot Media, the company that produced the video content described in this article, and were consultants on the National Institutes of Health grant that supported this work.

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Cho, M.K., Varsava, N., Kraft, S.A. et al. Metaphors matter: from biobank to a library of medical information. Genet Med 20, 802–805 (2018). https://doi.org/10.1038/gim.2017.204

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