The question posed at the end of part I of this series was whether Dr. Gregory House, central character in House, MD, practices medicine within any sort of ethical framework. Often accused of being unethical, and certainly uncaring, House claims to eschew the Hippocratic Oath, medicine’s sacred ethical charge. Much of what we see of House “caring” about patients, or anyone else for that matter, is played out in the subtext, most often revealed in the brilliant non-verbal acting of series star Hugh Laurie — through his expressive eyes and body language.
Although House seems to possess little regard for conventional ethics, I have come to the conclusion that he actually does operate from a reasonably well-defined set of ethical principles. Leading me to wonder further if the well-read House is familiar with the medieval philosopher Maimonides.
Maimonides is considered to be one of the greatest philosophers and thinkers of all time. A Spanish Jew who migrated to Egypt, he is revered as perhaps the greatest of the post-Biblical rabbis. His works include not only religious texts and commentaries, but treatises on logic (he was a rationalist), ethics, and medicine (he was also a renowned physician).
Maimonides is credited with a physician’s oath (actually the attribution is disputed by some), which presents several guiding medical principles. The ethical framework suggested by the oath is one that might resonate with our good, but grouchy, doctor:
May the love for my art actuate me at all time. If nothing else, House is passionate about the medicine; it certainly “actuates” him — it’s what keeps him going and what he lives for. It is, in essence, House’s lifeblood.
In season one, when Foreman has the opportunity to go back to work for his old mentor, "Dr. Marty" (as he is called by House), he notices a "difference in their styles." Dr. Marty is a laid back, but eminent, LA physician. Foreman sees him as forgiving and reasonable, two things that he clearly does not see in House. Admitting that Dr. Marty is a good doctor, House illuminates the real difference between them: “He thinks you do your job, and what will be, will be. I think that what I do and what you do matters. He sleeps better at night. He shouldn’t.” It's a defining moment early in the series, revealing House's passion for medicine — and what he sees as the importance of dedication to its practice.
Medicine seems to haunt House in his every waking moment; he can seldom turn it off (except when watching monster trucks or General Hospital, that is!). And, despite the fact that he claims chronic laziness, eschewing work (especially in the clinic) as if allergic to it, the medicine and his love for it probably is the only thing that motivates him to get out of bed on those days (as he told Detective Michael Tritter in “Words and Deeds”) when the pain is so bad it “sucks the soul right out of you.”
On the other hand, House’s love for the “art” of medicine, makes him avoid who he considers the boring, everyday patients in the clinic. And House does spend a lot of effort avoiding the dreaded clinic duty, seeing patients who can be equally well-served by a “monkey with a bottle of Motrin,” as he ranted in season one’s “Occam’s Razor.” However, once he’s in there seeing clinic patients, House usually becomes engaged (“actuated”), and does take the necessary time with patients, occasionally more than another doctor, pressured by a full waiting room and time constraints, might.
May neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind. One thing is certainly true, and that is that House is not motivated by avarice, the thirst for glory — or his reputation. And although season three's Detective Tritter may have been right in some respects about House’s relationship with drugs, he certainly was way off base in suggesting to Chase that House went into medicine because of the power it brings him. He couldn’t have been more wrongheaded.
Avarice? Despite House’s preference for expensive vintage guitars, no one could rightly accuse him of materialism and greed. (Okay, so he did awfully much like that vintage Corvette that the Arnello brothers gave him in “Mob Rules.”) He is not in medicine because it’s going to make him rich. In season one, the new hospital board chairman Edward Vogler orders House to lay off a staff member to cut costs. Agonizing over a way to avoid cutting anyone at all, House proposes cutting the salaries of the entire diagnostics staff, himself included: "Seventeen percent across the board will allow you to keep us all for the same amount of money. I believe it’s what you suits call 'win-win.'" It’s nearly a throw-away line, but the fact that House is willing to cut his own salary by 17 percent along with his staff salaries, says much about him, and the importance of money. Unfortunately, for Vogler, it was less about money than power — Vogler's.
House has little regard for his own reputation, and it's certainly not what drives him. It’s more than that he doesn’t care if people like him (or even respect him). If it is a choice between his reputation (or career) and serving the patient’s best interests (as he sees them), his reputation always loses. It’s not nobility; it simply doesn’t enter into the equation for him.
We’re aware from the very first episode that House is a doctor of some renown. “Your reputation still means something to this hospital,” Cuddy tells him in the series pilot. Clearly much of that reputation is for his particular gifts in diagnostics; however, as Vogler said to a cardiology gathering in season one’s “Role Model,” House also possesses a well-known reputation for integrity.
When given the option in “Role Model” to salvage his team by delivering a speech promoting a new (and not improved, but much more expensive) drug, House initially agrees to do it. But he struggles over the decision, telling Wilson that he’s selling his soul. “He’s not ordering you,” Wilson reminds House. “He gave you a choice. You chose your staff. I know this isn’t easy for you. You’ll suffer. Vicodin sales in Jersey will triple. But you are doing a good thing. Only you could feel like crap for doing something good.”
House tries to walk a fine line between saving his staff without selling too much of his soul, but in the end, he simply can’t do it, and instead of extolling the virtues of “Viopril,” House delivers a scathing indictment of Vogler’s company and the entire pharmaceutical industry: “Whenever one of his drugs is about to lose its patent he has his boys and girls alter it just a tiny bit and patent it all over again. Making not just a pointless new pill, but millions and millions of dollars. Which is good for everybody, right? The patients? Who cares about them? They’re just so damn sick! God obviously never liked them anyway.”
A more contemporary take on medical ethics, developed by a consortium of American and European doctors, "The Physician's Charter" states that the patient's interests be served without regard to "market forces, societal pressures or administrative exigencies." This is certainly something House would buy into. One of House's favorite rants skewers doctors valuing their their own lifestyles — or the hospital's bottom line — ahead of saving lives.
May I never see in the patient anything but a fellow creature in pain. Hmm. This is a tough one. Admittedly, House sees much of what comes into the clinic through a somewhat misanthropic lens. People are idiots wasting his time by coming in with illnesses that can be just as easily treated by taking an aspirin. But what about patients who come to him (even through the clinic) who are truly ill; who have futilely gone to doctor after doctor, only to come onto House’s service as a last resort?
Hugh Laurie has suggested (in one of the season three DVD featurettes) that House is “an old soul, someone who has seen a great deal of human suffering.” And I think House’s personal history influences how he treats his patients and how he views his own job and the profession of medicine.
The hyper-aware House is able to perceive suffering in another human being, and although his reaction to it may be (to say the least) quirky, abrasive, and distancing, it does affect how he responds. For example, in season three's “One Day One Room,” House wonders throughout the episode what draws rape victim Eve to him, like a moth to a candle flame. "Why me? Why do you want to talk to me?" he asks her several times. Ultimately she tells him that she sees in his suffering a kindred spirit, someone who might understand her because he “hurts too.” I think House has that ability, and tries (usually pretty successfully) to relegate it to a distant corner of his psyche, while promoting himself as the biggest jerk on the planet. I think "jerk" is a much more comfortable place for House to reside.
When House allows himself to get close enough, he does see his patients’ pain. And every once in a while, a patient really gets to House; gets under his skin. He more than sees their suffering; he understands it. He’s been there.
House’s poignant conversations with frightened and perhaps dying patients have been a hallmark of the series from the pilot episode onward. “We can only live with dignity,” an impassioned House tells the dying Rebecca Adler in the pilot episode, “we cannot die with it.”
In the season one episode “Control,” House treats Carly, a young woman who needs a heart transplant. Unable to condemn her to death because she’s bulimic and therefore fails to meet the transplant criteria, “right up there with suicidal,” House lies to the transplant committee to get her listed. “They would have had to condemn that poor girl; I’m not sure I could have done that,” House tells Vogler after he learns that House may have concealed the patient’s exclusionary condition from the committee. (And yes, I'm aware of the serious ethical issues involved — as someone else's patient may have died in order to give Carly a heart.)
In the season two episode “Euphoria,” Foreman has been infected by a deadly infectious agent after investigating a patient’s home. House pulls back on his usually aggressive medical approach, becoming cautious, “ordinary,” as Wilson accuses. Does the fact that it’s Foreman and not a stranger affect the way House approaches the diagnosis and treatment?
Most of the time, House puts himself so far distant from the patient that he objectifies them, enabling him to do whatever tests need to be done without regard to the patient's short-term pain and suffering — they're not people, they're patients. But Foreman can’t be objectified. He is not a nameless patient. He is Foreman, a subordinate, and someone for whom House is responsible. The fact that House is the one who sent Foreman into the lion’s den exacerbates the situation. When Wilson accuses House of being "common" and too passive in his diagnostic approach, House angrily asks him: “How many of your guys have caught cancer from their patients? Let me know when that happens. Then we can have this conversation.”
Later, as Foreman, still undiagnosed and now in terrible pain, wants House to perform a dangerous brain biopsy, House, baring his soul, tells Foreman a difficult truth, one House knows intimately and all too well: “Pain makes us make bad decisions. Fear of pain is almost as big a motivator. Now look, we still have time. I will do that biopsy if I have to, but not a moment before.”
Even when House does what he’s “supposed“ to do — like getting Eve in “One Day One Room” to “talk about” her rape — he wonders if he’s done the right thing. “Everyone will tell you,” he explains gravely to Wilson and Cuddy, “that that's what we gotta make her do. We have to help her, right? Except we can't. We drag out her story. Tell each other that it'll help her heal. Feel real good about ourselves. But all we've done is make a girl cry.”
Grant me the strength, time, and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements. Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. House would be the first to acknowledge his own fallibility as a physician. But that doesn’t mitigate his feelings about the dire consequences of mistakes. As he tells Chase in "The Mistake", "Mistakes are as serious as the results they cause! This woman could die because you were too lazy to ask one simple question!"
As he tells a lecture theatre full of medical students in “Three Stories:”
I’m sure this goes against everything you’ve been taught, but right and wrong do exist. Just because you don’t know what the right answer is – maybe there’s even no way you could know what the right answer is – doesn’t make your answer right or even okay. It’s much simpler than that. It’s just plain wrong.
In the aftermath of Lupe’s tragic death (due to both human error and “some bad decisions”) in season three’s “House Training,” House is reluctant in the next episode, “Human Error,” to pull the plug on a dying woman. What if it’s something simple, he wonders; something they just simply “missed.” “If we do an autopsy, you'll see… oops… if I'd thought of that crazy idea, we could have saved her,” he explains to Cuddy. Not knowing doesn’t excuse or absolve you, but understanding what went wrong and correcting it adds to the medical base of knowledge, so that the next time, perhaps you do get it right.
Medicine is not an exact science, and that's why it’s often still called an art. House always needs to know the “why.” What did they screw up? What did they miss? When House insists on knowing, it’s not necessarily simple curiosity, but, as Maimonides Physician’s Oath states, knowing allows him to “discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today.”
Now, I know that House is no knight in shining armor (I'd call him more of a knight errant), and his ethical lapses should not be minimized (and, if he were a real person instead of a fictional character, he would not survive very long in the real medical world). I also know that many fans of the series believe — and even applaud — the notion that House doesn’t care, and is simply in medicine to feed his “Rubik’s complex.” And for every example I’ve given there are counter examples to be had. And that's what renders the character of House so compelling. Uncaring bastard, who only cares when it serves his curiosity, or reluctant dark angel, who is compelled to fight off death and save the lives of the otherwise hopeless? Sometimes one; sometimes the other — but it certainly makes for a provocative television series, doesn't it?
And — speaking of provocative — the FOX official House site had posted three very interesting clips from the season five opener "Dying Changes Everything." However, the clips seem to have been removed. Hmmm! The season premieres Tuesday, September 16!