Science

The Ethics of Dr. Gregory House

Adam Kotsko

House both fulfills and questions its viewers’ fantasies of a medical utopia in which doctors are brilliant, attentive, and affordable

A friend of mine who works as a nurse once told me that I was insane if I thought House was an ethical person. She has a point. House avoids his patients and is unfailingly rude to them when he does see them. He continually torments his only friend, abuses his subordinates, and defies all authorities. And just for good measure, every few episodes someone reminds him (and us) that he has violated every ethical guideline in the book. Nevertheless, I’m convinced that House is one of the few properly ethical characters on TV today. Obviously I don’t mean “ethical” in the sense of being a generally good person, but rather in the sense of being devoted to a single unswerving principle: in House’s case, the quest for truth.

In the medical situation, the consequences of this principle should be clear: It demands that House properly diagnose his patient, letting no obstacles stand in his way. This dogged determination provides the central plot of each episode, which can to a certain extent function as a self-contained mystery similar to the various Law & Order franchises. House is different from Law & Order in a crucial way, however. While anyone can understand the various motivations and missteps that go into a murder and its detection, few of House’s viewers -- myself included -- can follow the medical reasoning on more than a very rudimentary level. Yet despite this problem, House is extremely popular. Not only was it the most popular scripted drama on television for the 2007-08 season, but it’s also in constant rotation on cable. Why?

It seems clear that Americans always enjoy watching a lone maverick make his own rules -- especially one as funny and engaging as House. But the show also touches on one of our most pressing contemporary problems: health care. House presents a medical utopia. An unparalleled medical genius and three (or in later seasons four) top-flight assistants all devote their full attention, at least most of the time, to the case at hand -- and no one ever asks how the patient is going to pay! The idea of health insurance only ever comes up in jokes.

The clearest demonstration of this utopian element is found in the first season's overarching plot. Edward Vogler, a wealthy businessman, makes a huge gift to the hospital in exchange for being made chairman of the board. It quickly becomes clear that his goal isn’t entirely altruistic: Vogler wants to use the hospital to run clinical trials for his company. More generally, he wants the hospital to run like a business, and his first target is House’s department, which is grossly inefficient. Vogler’s attempt to streamline the department quickly becomes a power struggle, with House absolutely refusing to budge. House’s friend Wilson -- the clueless Mr. Watson to House’s Sherlock Holmes -- and others chalk it up to sheer stubbornness on House’s part, but it is clear that something deeper is at stake. House won’t stand by and let the hospital be submitted to any non-medical demands. In the end, when it has become a choice between keeping House on staff or keeping Vogler’s money, the hospital chooses House. In other words, they vote for the medical utopia over economic realism. And who wouldn’t?

But here we find a paradox -- and a potential critique of the viewer’s utopian desires. At the center of this utopia is a character who is portrayed, at least in the early seasons, as antisocial and miserable. He’s a drug addict, he drives away women who love him, and he has only one friend, who subjects him to constant amateur psychoanalysis. The superficial explanation for all this is that House is in constant pain as a result of a leg injury, as revealed in the masterfully done episode “Three Stories.” Yet while the injury may make his antisocial behavior worse, it isn’t the root cause. Instead, the underlying problem is that his genius carries with it a tendency toward boredom. House is only fully engaged when tackling a difficult problem, and so he’s dismissive of simple medical cases because they’re simply over too fast.

That same impulse also makes him initially dismissive of people, because they so often seem to him to be cliché and replaceable. Figuring them out isn’t a challenge. This doesn’t mean House is indifferent to people. He is continually surprised by how interesting his clinic patients can be and of course the people closest to him (particularly Wilson) provide constant fodder for fresh investigations. Yet in the end, House’s obsession with truth means that he can never have a normal relationship. He acknowledges this most clearly when the love of his life, his ex-girlfriend Stacy, offers to take him back: House ultimately tells her that she shouldn’t get back together with him because he knows he’ll eventually get bored with her.

At the core of the medical utopia from which the profit motive has been banished, then, we do not find a doctor who is motivated solely by his love of humankind. If anything, as House comes to terms with his obsession over the first three seasons, the idea that he is motivated by compassion for patients winds up being excluded. The movement begins with a kind of resignation, symbolized by his acknowledgment that he can’t have a normal relationship with Stacy. In first few episodes of the third season, however, he comes to believe that he has lost even his unique diagnostic genius and enters into a deep depression; his gift has cost him a normal life, and then even the gift has apparently been taken away. He turns out to be mistaken, but the message is clear: His quest for truth is the only thing that makes House’s life fulfilling.

The third season also explores House’s relationship with one of his subordinates, Foreman. After effectively killing a patient with a faulty diagnosis, Foreman take a more cautious approach that makes House worry that Foreman has lost his edge. But Foreman proves himself in a later episode, in which he recognizes that the only way to save two young boys is to perform an extremely painful procedure on one of them without sedation, effectively torturing him. Believing himself to have acted “like House” -- that is, like a moral monster who subordinates human need to medical effectiveness -- Foreman submits his resignation, after the very act that wins House's trust and approval back. He has done his job with ruthless effectiveness and saved two lives against enormous odds, but he can’t handle what the necessary indifference to normal human concerns is turning him into.

The conflict between House and Foreman comes to a head in a later episode in which House, under the influence of antidepressants that Wilson has surreptitiously slipped him, is deeply satisfied with himself for having “called” a diagnosis from only the most minimal clues -- yet ignores the fact that the diagnosis is untreatable and the teenage patient will die. The whole team is scandalized, especially Foreman, for whom it basically confirms that House is indeed a moral monster. On his last day on the job, Foreman explains that unlike House, he wants to practice medicine for the sake of the people rather than the intellectual satisfaction. At first, House retorts that patients don’t care about his motivations, but the message of the episode and the season seems broader: House’s satisfaction in his diagnoses make him so effective. Only by practicing medicine for its own sake and not for the people, and directly enjoying its inherent satisfactions, can he ever hope to solve the hopelessly complicated cases that he is faced with.

By the end of the third season, the “concept” behind House's character is completely developed. In later seasons, we see House simply enjoying being House, most notably in the elaborate game he devises to hire a new team of assistants. It’s an open question how much more the writers can really do to keep the show going at this point, short of employing standard soap-opera techniques -- which unfortunately seems to be the route they’ve chosen recently. But one potentially interesting avenue, especially now that House’s “monstrous” ethical stance is fully established, is in his relationship with his former subordinate Cameron. Where Foreman provided a mirror by means of which House could come to terms with his own ethical principle of searching for truth, Cameron represents a different but equally strong ethical principle: compassion. In one episode, for example, she befriends a terminal patient with no family or friends. When one of her colleagues cautions Cameron against getting too involved, her response is a principled declaration that someone should be upset “when a good person dies.” In a sense, this stance is just as utopian as House’s relentless quest for truth, and it can be just as costly on a personal level, exposing the doctor to an ever-increasing weight of personal loss.

House complains that doctors who act like they care are just flattering their own egos or soothing their consciences, but that’s not what the writers want us to think about Cameron. So it's a shame that the recent subplot with Cameron taking Cuddy’s place as administrator was cut off after only one episode. The question that Cameron could have been used to bring to the fore is how to reconcile the inhuman aspects inherent to House’s medical approach -- symbolized by his refusal to even talk to his patients directly in many cases -- with the very human element that patients also hope for from their doctors. House treats the patient's body like a machine that isn’t working right, and that, the show insists, is what makes him so remarkably effective. An extended conflict between the two could have dramatized an important question: Is emotionally sensitive care for a patient something that’s simply tacked on to the medical task, or can it be more fully integrated?

The show consistently reminds us that the answers to these questions aren't easy. Finding a way to remove the profit motive from medicine in America may seem like a nearly impossible and utopian task in itself, yet House shows us that that is perhaps the easiest step. Once that is done, it only opens the door to more difficult and pressing questions.

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