The popular television series House M.D. is drawn upon to provide a critical examination of medical paternalism and how it is presented in the show. Dr Gregory House, the character named in the title of the series, is a paradigm of a paternalistic physician. He believes that he knows what is best for his patients, and he repeatedly disregards their wishes in order to diagnose and treat their illnesses. This paper examines several examples of medical paternalism and the means used to portray it favourably in the series. It is argued that the positive depiction of medical paternalism in the fictional world of the series does not apply in the real world. The paper also considers why a show that features a paternalistic physician who so blatantly flouts mainstream medical ethics might appeal to health professionals and members of the general public.
- medical ethics
- medical humanities
- medicine and television
- House M.D.
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House M.D. is a widely acclaimed and very successful television series about medicine, produced in the USA and broadcast in the UK and 10 additional countriesi. The series features a physician, Dr Gregory House, who heads a “Department of Medical Diagnostics”, and each episode features a challenging search for the diagnosis of a patient’s symptoms. Accordingly, the series might be characterised as a “medical mystery”. Indeed, in an interview, the producers stated that the choice of the name House was a pun on Holmes (homes); and the name of House’s physician friend Wilson was chosen because of its similarity to Watson.1
In the final scene of “Honeymoon”, the last episode of the first season of House M.D., Dr House listens to a Rolling Stones song, and we hear Mick Jagger sing, “You can’t always get what you want, but if you try sometimes, you might find, you get what you need ...” These words express a recurrent paternalistic theme of the series: patients don’t always get what they want (that is, their preferences and choices are disregarded), but they get what Houseii believes they need (that is, tests, medical procedures and medications that enable him to successfully diagnose and treat their medical conditions).
House is a paradigm of a paternalistic physicianiii. He believes that he knows what is best for his patients, and he repeatedly flouts their wishes in order to diagnose and treat their illnesses. For him, informed consent is a meaningless ritual and, worse yet, a potential obstacle to providing patients the tests, medical procedures and medications that he believes they need. Accordingly, House M.D. is an excellent vehicle for an analysis of medical paternalism.
INSTANCES OF MEDICAL PATERNALISM IN HOUSE M.D.
One of the most extreme and dramatic examples of medical paternalism in the series occurs in “Honeymoon”. In that episode, a patient named Mark refuses to allow House to perform a diagnostic test. Mark, the husband of Stacy, House’s former fiancée, is completely paralysed. House believes he knows the cause of Mark’s symptoms: acute intermittent porphyria. To confirm the diagnosis, House proposes to trigger a seizure with an injection and then perform a test on a urine sample. Triggering seizures is risky, and Mark refuses. However, at Stacy’s urging, House carries out his recommended plan despite the protests of Mark and each of the three members of the medical team (Cameron, Chase and Foreman).
As the following list indicates, in addition to “Honeymoon”, the first three seasons of the show are rife with episodes in which House acts paternalistically by providing or ordering medical interventions that he believes patients need rather than what they want:
“DNR” (season 1). A paralysed famous horn player named John Henry Giles experiences difficulty breathing and is admitted to Princeton–Plainsboro Hospital. Based on the diagnosis of a prominent physician 2 years earlier, John Henry believes he has ALS, an incurable, progressive disease, and he insists on a do-not-resuscitate (DNR) order. However, when Henry experiences respiratory failure, House intubates (initiates mechanical ventilation), contrary to the DNR order. John Henry continues to refuse treatment, but House persists, because he does not accept the diagnosis of ALS. Despite John Henry’s protests, House wheels him in his hospital bed to get an MRI.
“Spin” (season 2). Towards the end of the episode, House walks into a patient’s room and gives him a diagnostic injection without informing him. It is only after the injection temporarily reverses the patient’s symptoms that House explains the purpose of the injection and the meaning of that temporary reversal.
“TB or not TB” (season 2). A physician named Sebastian Charles, who is committed to providing tuberculosis medication to poor villagers in Africa, presents at Princeton–Plainsboro Hospital. House suspects that although Sebastian has tuberculosis, that disease is not his primary life-threatening condition. House proposes to treat the tuberculosis so that he can make an accurate diagnosis on the basis of the symptoms that persist. However, Sebastian does not want to accept the expensive drugs that would be needed to treat his drug-resistant tuberculosis because he thinks his death might help to publicise the plight of tuberculosis patients who cannot afford expensive medicines and bring pressure on pharmaceutical companies to make drugs more affordable and accessible. House pressures Sebastian to take the tuberculosis medication by threatening to undermine his plan by disclosing, after his death, that he did not die of tuberculosis.
“Who’s your daddy?” (season 2). House performs a paternity test against the wishes of Crandall, a former friend. House does not tell Crandall that he has performed the paternity test. The test is negative, but House tells Leona, a patient who claims to be Crandall’s daughter, that it is positive.
“Informed consent” (season 3). The patient, Ezra Powell, is a renowned 71-year-old medical researcher and author of an important medical textbook. He is admitted to the hospital after experiencing respiratory failure. When initial diagnostic efforts fail, he observes that he is old and sick and expresses a wish to die. Subsequently, he attempts to commit suicide by wrapping medical tubing around his neck. House secures Ezra’s agreement to give him one more day to try to diagnose his condition by promising to help Ezra die if the diagnosis is not determined within that period. No diagnosis is found by the end of the 24 hours and Ezra refuses to give House additional time. House gives Ezra an injection of morphine, but when he goes into respiratory arrest, House intubates Ezra and orders that he be placed on a mechanical ventilator. House then proceeds to perform additional tests in an effort to determine the cause of Ezra’s symptoms.
Although House is responsible for much of the paternalism in the series, on more than one occasion, Cameron, who is generally the moral conscience of House’s medical team, undertakes a paternalistic action. In “Que sera sera” (season 3), when she cannot convince a patient to remain in the hospital, she forces him to stay against his will by secretly giving him three grams of phenytoin, which produces disorientation and loss of balance. In “Informed consent”, despite Ezra’s refusal, Cameron cuts a patch of his skin so that a biopsy can be performed.
Both House and a member of his medical team (Foreman) are themselves on the receiving end of paternalism. In “Three stories” (season 1), we see House as a patient whose wishes are over-ridden for his own good. In this episode, while giving a lecture to medical students, House refers to his own past experience as a patient, and we see the events he describes in a flashback. House is in severe pain due to muscle necrosis in his leg. Cuddy, who currently is the hospital administrator, was his physician then. She recommends an amputation, claiming it is necessary to save his life, but House refuses. He is willing to risk dying in order to have a chance of regaining full use of his leg, and he wants to be put in a temporary drug-induced coma for relief of pain. After House loses consciousness, Stacy, his fiancée at the time, asks Cuddy to perform a procedure that is expected to give House a better chance of surviving. Both know that House does not want the procedure, but it is performed with Stacy’s approval. He receives the treatment that Stacy and Cuddy believe he needs rather than the treatment he wants.
In the second part of the two-part episode entitled “Euphoria” (season 1), Foreman is subjected to paternalism. He has contracted an unknown disease from a patient who died. Since Legionnaire’s disease appeared to slow the progress of the other patient’s illness, House proposes to infect Foreman with the disease to buy time to enable him to discover the correct diagnosis. Foreman rejects House’s plan, shouting, “I’m not consenting to you giving me …” However, before he can complete the sentence, House throws a glass vial with Legionella pneumophila onto the floor, causing it to shatter and infect Foreman against his wishes.
MEDICAL PATERNALISM AND ETHICS: HOUSE VERSUS MAINSTREAM MEDICAL ETHICS
Paternalism is clearly against the norms of mainstream medical ethics. Informed consent—the principle that, except in emergency situations, medical interventions require the voluntary and informed consent of patients or their surrogates—is a core ethical principle in healthcare.3 4 A corollary of informed consent is that patients who are able to decide for themselves have a right to refuse treatment recommendations. Another core principle is that when patients lack decision-making capacity, surrogates should make decisions in line with the wishes and values of the patient. Both of these principles reflect a strong opposition to paternalism in contemporary medical ethics. Yet House repeatedly acts paternalistically without giving it a second (or even first) thought. Is he right, and is the antipaternalism of mainstream medical ethics wrong; or is House mistaken and is a strong moral presumption against medical paternalism justified?
The presentation of medical paternalism in the fictional world of House M.D.
As to be expected, the series provides viewers with several reasons for deciding in favour of House’s assessment of medical paternalism. Time after time, when he gives patients what he believes they need rather than what they want, the outcome appears to be better for the patients than it would have been if they had received what they wanted. Accordingly, a recurrent message appears to be that doctors—or, at least, Dr House—do indeed know what is best for patients, and that the good outcomes for patients justify medical paternalism. This message is reinforced when patients acknowledge that they benefited from it. Most are pleased with the good outcome and express no anger or resentment. Some even express gratitude.
In “Honeymoon”, the test House performs despite Mark’s protests confirms the suspected diagnosis, and House orders the indicated treatment. We later see Mark, who is no longer paralysed, jokingly ask Stacy whether she wants to arm wrestle. They are both very happy, and Mark does not criticise House’s failure to respect his wishes. Mark’s only comment about House is “He’s still a maniac”. The Rolling Stones song at the end of the episode drives home the paternalistic message that giving patients what they need is more important than giving them what they want.
In “DNR”, the MRI performed against John Henry’s wishes reveals a blood clot. After the clot is removed, another MRI reveals that a previously undetected arteriovenous malformation, and not ALS, is the cause of John Henry’s paralysis. At the end of the episode, as John Henry walks out of the hospital, he meets House and says, “Thanks for sticking with the case.” If John Henry’s wishes had been respected, he would have been dead rather than walking out of the hospital. Once again, it appears that House knows best and that medical paternalism has prevented an unnecessary and premature death, a result for which the patient is grateful.
In “Three stories”, House does not criticise the paternalistic treatment to which he was subjected. He survived the surgical procedure that was performed contrary to his wishes, and he did not lose his leg. However, he suffers severe chronic pain and cannot walk without a cane. Despite this somewhat mixed result, an exchange among three medical students and House at the end of the lecture appears to endorse the decision to over-ride House’s wishes:
House: “Because of the extent of the muscle removed, the utility of the patient’s [House’s] leg was severely compromised. Because of the time delay in making the diagnosis, the patient continues to experience chronic pain.”
First medical student: “She [Stacy] had no right to do that.”
Second medical student: “She had the proxy.”
First medical student: “She knew he didn’t want the surgery.”
Second medical student: “She saved his life.”
Third medical student: “We don’t know that; maybe he would have been fine.”
First medical student: “It doesn’t matter. It’s the patient’s call.”
Second medical student: “The patient’s an idiot.”
House: “They usually are.”
True to form, House’s negative assessment of the intelligence of patients is provocative and exaggerated. Nevertheless, it affirms the paternalistic conclusion that patients, including House, don’t know what they need.
In one episode, “Informed consent”, medical paternalism does not appear to benefit the patient in the end. The tests that are performed against Ezra’s wishes succeed in providing a definitive diagnosis. However, the news is bad: Ezra has protein type AA amyloidosis, which is a terminal form of the disease. Still, a plausible reading of this episode is that since the unwanted tests might have revealed a treatable condition, performing them was in Ezra’s best interests. Indeed, when the diagnosis of amyloidosis is first confirmed, Cameron says, “That means it should be treatable.”
There are a few episodes in which paternalism is resisted and patients are given what they want rather than what House or another member of the medical team believes they need. In “Pilot”, a young woman named Rebecca is admitted after experiencing seizures. After a mistaken diagnosis, she loses trust in the medical team and refuses further medical tests and procedures. When the team determines that her symptoms are caused by a tapeworm in her brain, Rebecca continues to refuse invasive procedures and states that she wants to be allowed to die. Although House initially accepts her decision, Chase suggests that an x ray examination, which is a non-invasive measure, can convince Rebecca that they have the correct diagnosis this time and persuade her to accept treatment. The x ray image reveals tapeworm larvae in Rebecca’s thigh, and after seeing the image, she changes her mind and accepts treatment. Accordingly, although paternalism was resisted in this episode, the team was able to provide the treatment they believed the patient needed without over-riding her wishes.
In each of two other episodes in which medical paternalism is resisted—“Forever” (season 2) and “One day, one room” (season 3)—grounds are suggested for questioning the decision to respect the patient’s wishes. In “Forever”, a hospitalised young woman named Kara kills her infant son, Michael, who is a patient in the neonatal intensive care unit. The team determines that she has pellagra, which explains her hallucinations and the voices that urged her to kill Michael. Coeliac disease, which is the cause of Kara’s pellagra, has also caused cancer of her stomach lining. She is guilt-ridden for having killed Michael, but House attempts to persuade her that because of her pellagra-induced psychosis, she is not responsible for Michael’s death. He tells her, “This is not your fault … You do not deserve to die.” However House fails to convince Kara, and she refuses treatment by responding, “I don’t want to live.” In the next scene, which begins with House reporting Kara’s decision to Foreman, there is the following exchange:
House: “She said no.”
Foreman: “So we get her declared unstable, appoint a medical power …”
House: “She was unstable. Now she’s sane. She’s entitled to refuse treatment.”
Foreman: “You have to change her mind, you can’t just walk away.”
Ironically, although House does “walk away”, this may be a case in which the patient’s current wishes should not have been honoured. She may not be “insane”, but she clearly is emotionally distraught, and her thinking and judgement may be impaired as a result. At the very least, viewers might well agree with Foreman that other options should have been explored before walking away.
In “One day, one room”, a homeless patient who is dying of an inoperable tumor refuses treatment and Cameron reluctantly respects his wishes. He later insists that he be allowed to die without pain medication so that he will be remembered. He tells Cameron, “I have no family. I have no friends. I didn’t even have a real job. If I die in peace, then I’m just another patient, but if I die suffering … I just need to die knowing that something is different because I was here.” Cameron tries to persuade the patient to accept pain medication. She begins to give it to him despite his refusal, but stops and respects his wishes. She sits at his bedside as he dies. In view of the patient’s perplexing request, this emotional scene might well prompt viewers to question whether Cameron made the right choice when she rejected paternalism and witnessed the patient’s painful death in accordance with his wishes.
The ethics of medical paternalism in the real world
Although the case for medical paternalism in the fictional world of House M.D. may seem to be compelling, the appropriateness of the practice in the real world remains to be considered. In many respects, the fictional world of House M.D. is a fantasy. By the end of each episode, House and his team usually have successfully identified and treated the patient’s illness. Unfortunately, in the real world, diagnoses and prognoses are significantly more elusive, and there are many chronic, untreatable and terminal diseases. For example, in “Honeymoon”, House’s diagnosis was correct, and Mark received the medically indicated treatment and was well on the road to recovery by the end of the episode. But in the real world, a physician’s diagnosis might have been mistaken, and the test that House administered against Mark’s wishes might have killed him. In “DNR”, House’s belief that John Henry does not have ALS is confirmed, and surgery reverses his paralysis. In the real world, however, the first physician’s diagnosis might have been correct, and the patient might have been subjected to pointless tests and interventions that increased his discomfort and thwarted his desire to die with dignity. Surely, viewers would be less inclined to accept House’s paternalistic actions if Mark had died as a result of the test or if it had not confirmed House’s diagnosis, or if John Henry had had ALS. Yet both outcomes were distinct possibilities when each decision was made.
In the real world of medicine, when decisions are made about tests and therapies, the outcome is unknown. At best, probabilities can be assigned to various outcomes and the potential benefits and harms associated with each. Accordingly, the medical paternalism of House and his team should be assessed when a decision has to be made, based on what is known at the time, and not after the fact, when the outcome is known.
In the world of House M.D., patients are usually grateful after House disregards their wishes and succeeds in diagnosing and treating their illnesses. However, in real life, patients are not always so forgiving when doctors disregard their preferences and choices. It is instructive to compare the reactions of Mark and John Henry, who were pleased and appreciative, with the reaction of a well-known actual patient, Donald (Dax) Cowart, who was subjected to medical interventions against his wishes.5 In July 1973, at the age of 25, Dax suffered severe burns over much of his body as a result of a propane gas explosion. Suspecting the seriousness and extent of his injuries, Dax asked the first person he encountered after the explosion, a farmer, to give him a gun so he could shoot himself. The farmer refused, and Dax, despite his protests, was taken to a hospital, where he again insisted that he did not want treatment. Despite his continued protests and a psychiatrist’s finding that he was competent, Dax was forced to undergo extremely painful burn treatments. He survived, but he was blind and badly scarred, he lost the use of his arms, and his fingers were amputated.
Dax’s hardships did not end when he was discharged from the hospital 14 months after the accident. He encountered a number of obstacles and setbacks, including depression, insomnia, divorce, a failed business venture and dropping out of law school twice; and he attempted suicide more than once. However, more than a decade after the accident, he graduated from law school and his life was on a more positive course. Ultimately, he was satisfied with his quality of life, he considered his life worthwhile, and he was glad to be alive. However, Dax remained angry that his wishes had not been respected, and he became an advocate for patients’ rights, in particular the right to refuse medical treatment.
Why, it might be asked, is Dax angry and resentful? After all, he admits that he is enjoying life, and but for the medical paternalism of his doctors, he would be dead. In a documentary about him entitled Dax’s case,6 he offers two reasons. First, he believes that the means (that is, the excruciating pain and extreme suffering associated with the burn treatments that he endured for months) did not justify the end (that is, preventing his death). Accordingly, Dax says that even if he knew the outcome would be the same, if he had to make the choice again, he would still refuse treatment. Second, he says he values freedom and the ability to choose for himself. Accordingly, he is angry that others (for example, his mother and physicians) decided for him.
Dax’s first reason helps to expose a fallacy in the notion that a brilliant clinician such as House knows what is best for patients. Thanks to their medical training and expertise, physicians may know best how to keep their patients alive. However, keeping a patient alive will not necessarily promote the patient’s good or best interests. When there are treatment options (non-treatment is always one option), determining which is best for a particular patient (that is, evaluating the potential benefits and harms) depends on that patient’s distinctive preferences and values. As a popular idiom puts it, “different strokes for different folks”. For example, for Dax, but not necessarily for all patients in a similar situation, avoiding the pain and suffering associated with burn treatments was more important than preventing death. Accordingly, even though the outcome for him was good, it cannot be said that treating him against his wishes promoted his best interests better than forgoing treatment would have.
Dax’s case also challenges the recurrent notion in the series that medical paternalism is justified because House and his team provide patients what they need. What do patients need? House’s answer is: health and longevity. But, as Dax illustrates, patients can have goals and values other than health or longevity. Dax valued freedom and the absence of pain, and he assigned higher priority to both than to health and longevity. As House himself illustrates in “Three stories”, patients can value bodily integrity more than life, in that they are willing to bear an increased risk of death in order to keep a limb or breast or in order to reduce the risk of incontinence, sterility or impotence. Ezra, in “Informed consent”, placed a very high value on death with dignity. Clearly, then, although patients may need certain medical interventions to stay alive, it does not follow that they need those interventions to promote their good (that is, the goals that matter most to them).
The patient/physician in “TB or not TB” provides an additional and very striking illustration of this point. He was willing to die in order to promote the goal of making tuberculosis medication more widely available to African villagers. He might have “needed” treatment in order to stay alive, but did he need treatment in order to promote his good? There is no “objective” medical answer to this question, because ultimately the answer depends on his distinctive values and priorities. Lest one think that no rational person would give up his life for the sake of others, remember that parents who are willing to risk their lives for their children and soldiers who are willing to die for their country and/or fellow soldiers are praised for their virtue rather than criticised for their flawed judgement.
Even when the discussion is limited to considerations of health, it is mistaken to think that there always are objective standards for ascertaining patient’s needs. In “Honeymoon”, did Mark need the test that House recommended? If health is the exclusive goal and the test is the only effective means of restoring his health, House might plausibly claim that he needed it. But in the real world, the situation is much more complex. Tests have potential benefits as well as risks, and forgoing tests also has potential benefits as well as risks. In Mark’s case, the test might have provided a decisive diagnosis of his illness, but it also might not. It might have caused a further deterioration in his health or even led to his death. Even if the test led to a correct diagnosis, the treatment might not have been effective. On the other hand, without the test, Mark might have died, but his health also might not have worsened or it might even have improved. House might have been wrong, and the correct diagnosis might have been discovered, or there might have been a spontaneous remission. There is no “objective” standard for weighing all of these potential benefits and harms and determining whether the potential benefits of the test House recommended outweighed the risks. Accordingly, there is no “objective” right answer to the question, did Mark need the test? The answer to this question requires value judgements, and Mark’s answer might or might not have been the same as House’s or another patient’s.
In the world of House M.D., choices typically are life-or-death choices: if a patient doesn’t receive a certain medical intervention, the patient will die. However, in the real world, choices are not always so stark. Decisions about back, knee, bunion, deviated septum or prostate surgery, or about medication for severe acne and countless other conditions, are not life-or-death choices. In such cases, patients must weigh the potential benefits and risks and determine whether the probability and amount of the potential benefits are high enough to outweigh the risks. If, after careful consideration, a competent patient decides against having the procedure, it would be unwarranted for a physician to insist that the patient needs it.
Even when choices in the world of the series are not between life and death, they are sometimes presented as being limited to only two options. For example, Cameron’s choice in “One day, one room” is presented as a choice between paternalistically administering pain medication against a dying patient’s wishes and doing nothing to prevent the painful death the patient said he wanted. However, in the actual world, there are other possibilities. One obvious course of action would have been to determine whether the patient was clinically depressed and, if so, whether medication could benefit him. Another option, one that could have been pursued simultaneously or as an alternative, would have been to explore the patient’s wishes in greater depth. In particular, Cameron might have tried to determine what the patient really wanted. He said he wanted to suffer as he died, but suffering was merely a means to his stated goal: “knowing that something is different because I was here”. In effect, his goal was to leave some “trace” of himself that would remain after his death (that is, Cameron’s lasting memory of his painful death). Cameron might have talked to him to try to discover ways in which he had already accomplished this goal through his past actions and relationships. She might have invited him to think about his life when he was younger and reconsider whether it was as empty and devoid of meaning as he now thought. She also might have questioned why the patient believed that having her witness him die in pain would accomplish his goal. Pursuing such questions with the patient might have spared Cameron from having to choose between paternalism (that is, administering pain medication against the patient’s stated wishes) and passively witnessing the painful death he said he wanted.
Dax’s second reason for his anger and resentment is connected with an important concept, autonomy, and a corresponding ethical principle, respect for autonomy, which provides the basis for another challenge to the medical paternalism practised by House and his team. To say that a person is autonomous implies that the person is self-governing. An autonomous or self-governing person has (1) more or less stable and coherent goals and values that are the person’s own, in the sense that they have become internalised, and the person recognises them as her own and definitive of who she is; (2) the ability to make informed decisions based on the person’s goals and values and (3) a disposition to exercise these capacities. Autonomy and its unhindered exercise contribute to a person’s dignity and sense of self-worth, moral agency and wellbeing; and, as Dax so vividly demonstrates, people want to be able to exercise their autonomy. Accordingly, even if House and his team effectively diagnose and treat a patient’s illness, when they disregard the patient’s choices they fail to respect the patient’s autonomy, which can have a significant moral cost.
The value of autonomy is confirmed by a thought experiment proposed by Robert Nozick.7 Imagine there is an “experience machine”, a device that can be connected to people’s brains that will produce experiences that make them feel happy. For example, if bowling a score of 300, writing a book that is heralded as the most important contribution to philosophy in 50 years, owning a 25-room mansion on a picturesque hillside overlooking the Pacific Ocean, receiving a tenured position at Harvard and marrying Catherine Zeta-Jones are experiences that will make a person happy, the experience machine can be programmed to produce those experiences. What would be missing is a sense of agency. In so far as the machine has produced those experiences, the person has not exercised autonomy. The person has done and accomplished nothing. The medical paternalism practised by House and his team may make patients happy in the end, but, like the experience machine, it does not enable them to exercise their autonomy. The experience machine and Dax serve to remind us that people may value the ability to exercise their autonomy more than they do happiness.
Hopefully, most physicians do not agree with House that patients usually are “idiots”. But respect for autonomy may on occasion require a physician to honour a decision that is perceived to be a “mistake” or a “bad” choice. Freedom to make decisions only if they are “correct” or “good” is no real freedom and does not enable patients to exercise their autonomy. Accordingly, it might be said that a price of the exercise of autonomy is the risk of making bad decisions. Nevertheless, respect for autonomy does not require physicians to passively allow patients to make perceived bad decisions. Recommending tests, procedures and medications to patients and attempting to persuade them to accept those recommendations is compatible with respect for autonomy. Indeed, patients may benefit from efforts to help them exercise their autonomy. Such efforts can include helping patients identify and prioritise their values, understand complex medical information, assess benefits and burdens and deal with fears and anxieties. Respect for autonomy requires only that if a physician’s efforts to convince an autonomous patient fail, the physician, unlike House, should respect the patient’s decision to refuse a recommended test, procedure or medication.
The many reasons for challenging medical paternalism in the real world support a strong presumption against it. However, it would be unwarranted to conclude that medical paternalism is never ethically justified. When evaluating paternalism, it is important to distinguish between cases in which agents are fully autonomous and capable of making decisions for themselves, on the one hand, and, on the other hand, cases in which agents lack decision-making capacity or in which their reasoning ability is deficient or impaired. Accordingly, the antipaternalistic stance of mainstream medical ethics applies to autonomous adults, but not to infants, young children or adults with severe mental retardation or advanced dementia. Moreover, autonomous persons can suffer temporary diminished autonomy as a result of illness, medication, accidents or traumatic life events. A previously described scene from “Forever” illustrates this point. Having recently killed her son during a pellagra-induced psychotic episode, Kara is guilt-ridden and emotionally distraught. She rejects treatment for stomach cancer because she doesn’t want to live, not because she has concluded that the expected benefits of treatment do not outweigh the expected burdens, and the statement that she does not want to live may stem primarily from guilt and depression. Thus, even if House is correct to proclaim that she is no longer “insane”, it is likely that her thinking and judgement are temporarily impaired, and there is good reason to question whether acceding to her stated wishes will promote her enduring goals and values. A similar observation applies to Dax. For a period of time after the accident, his decision-making abilities might have been significantly compromised because of his injuries. Several months later, however, when Dax still was being treated contrary to his wishes, a psychiatrist determined that he had decision-making capacity. Unfortunately, determining patients’ decision-making capacity can be very challenging in practice, but it is noteworthy that House shows little interest in getting this “diagnosis” right.
Generally, the case for rebutting the presumption against medical paternalism is strongest when it is undertaken to prevent harm to the patient and the standard of harm is based on the patient’s own standards of harm and benefit rather than the standards of others (for example, of physicians or family members). Other relevant factors to consider include (1) the magnitude of the expected harm to the patient, (2) the probability that the harm will occur in the absence of paternalistic intervention, (3) whether the expected harm is imminent, (4) whether there are alternative means to prevent the harm and (5) the likelihood that the contemplated paternalistic intervention will prevent the expected harm. In some situations, these criteria will provide an unambiguous answer. Ezra’s story in “Informed consent” may illustrate this type of case. However, in other situations, it may be possible for reasonable people to disagree. House’s experience as a patient in “Three stories” and the significantly different responses of the three medical students may well exemplify a case of this kind. In any event, House to the contrary notwithstanding, real-world physicians cannot justify medical paternalism by maintaining simply that patients are “idiots”. Determining whether medical paternalism in the real world is ethically justified calls for considerably more nuanced reflection and ethical analysis than is evidenced in the fictional world of House M.D.
Paternalism and the appeal of House M.D.
The series received an Emmy Award for Outstanding Writing for a Drama Series (2005), was twice nominated for an Emmy in the Outstanding Drama Series category (2006 and 2007) and was nominated for a 2008 Golden Globe Award for Best Television Series—Drama. In addition, Hugh Laurie received two Golden Globe Awards for Best Performance by an Actor in a Television Series (2006 and 2007), a Screen Actors Guild Award for Outstanding Performance by a Male Actor in a Drama Series, and two Emmy nominations for Outstanding Lead Actor in a Drama Series (2005 and 2007)iv. House M.D.’s high rankings in the Nielsen Media Research ratings attest to its popularity in the USA. For example, the series ranked fifth in number of viewers (18.03 million, versus 19.79 for the program with the most viewers) for the week of 8–14 October 2007, and for the entire season to that date.8
In my own experience teaching medical students and undergraduate premedical students, I have found that those who are familiar with the show tend to be avid fans. I often use clips from the series when I give presentations to healthcare professionals, and their reaction has tended to be much more mixed. Physicians’ responses, in particular, have tended to be either strongly positive or strongly negative. Those who dislike it often cite the series’ lack of realism. Paradoxically, this feature may help to explain its appeal as well.
In the world of the series, House is able to decide what is best for patients, and, in the end, his decisions appear to have been right. He has discovered the diagnosis and the treatment, he is hailed for his brilliant clinical skills, and his paternalism is tolerated, excused or even endorsed. He repeatedly flaunts ethical, legal and institutional rules and challenges the authority of Cuddy, the hospital administrator, but because of his clinical brilliance (his repeated success in diagnosing and treating illnesses), his “bad behaviour” generally is tolerated, if not encouraged. Until the third season, the most severe “punishment” he faced was to be required to spend more time seeing clinic patients. Fiction, perhaps, but this unrealistic world may have considerable appeal as a fantasy to physicians who may desire to be right all or most of the time and who may be frustrated by the real-world constraints, obstacles and disappointments that they confront.
Whereas mainstream medical ethics encourages doctors to treat patients as persons, House tends to treat them as organisms with diseases and as challenges for his clinical skills. His attitude towards patients is already revealed a few minutes into the series pilot, in the following exchange:
Foreman: “Shouldn’t we be speaking to the patient before we start diagnosing?”
House: “Is she a doctor?”
Foreman: “No, but …”
House: “Everybody lies.”
Cameron: “Dr House doesn’t like dealing with patients.”
Foreman: “Isn’t treating patients why we became doctors?”
House: “No, treating illnesses is why we became doctors. Treating patients is what makes most doctors miserable.”
Foreman: “So you’re trying to eliminate humanity from the practice of medicine.”
House: “If we don’t talk to them, they can’t lie to us and we can’t lie to them. Humanity is over-rated.”
When House does speak to patients, his “bedside manner” typically is atrocious, and he often is rude, abrasive, insulting and/or mocking. He frequently tells patients exactly what he thinks about them, and it is rarely positive. In the fictional world of the series, House’s behaviour is tolerated. In the real world, by contrast, few hospital administrators, patients or family members could be expected to tolerate such extreme behaviour. This point can be illustrated with a scene from “Poison” (season 1). To get a boy’s mother to consent to recommended treatment that she has refused, House reads her a form that allegedly releases the hospital from liability if her son “kicks off” (that is, dies) and characterises her decision as “completely idiotic”. It also mocks her by suggesting that she believes that she is qualified to make the decision because she took a biology course. Whereas House’s strategy works in the show, an actual mother might be more likely to “fire” House, seek another physician and file a complaint. Once again, although some health professionals may perceive this unrealistic character of the series as a flaw, for others it may represent a fantasy or wish fulfilment. For the latter, and for medical students, the series may provide an opportunity to vicariously flaunt rules and release frustrations derived from encounters with “difficult” or “noncompliant” patients and family members.
What about the general public? To be sure, House’s “bad behaviour” is often humorous, and the show is entertaining. However, entertainment value aside, in a culture that places a high premium on consumer rights, self-determination and freedom of choice, what might members of the general public find appealing about the medical paternalism of House and his team? Might the series represent a type of fantasy and wish fulfilment for them as well? At a time when more and more Americans appear to share the view of the healthcare system that is presented in Michael Moore’s film Sicko—a system in which the profits of corporations such as insurance companies, health plans and pharmaceutical companies have priority over the health of patients—House’s no-holds-barred commitment to the health of the individual patient and his success in achieving that objective may have considerable appeal. For many viewers in other countries, as well, the attractive features of this fantasy compared with the realities of their respective healthcare systems might be powerful enough to overshadow the limitations of House’s paternalism and bedside manner.
↵i The other countries are Germany, Finland, Spain, Singapore, Ireland, Netherlands, South Korea, Chile, Argentina and Australia. This information is from the Internet Movie Database: http://www.imdb.com/title/tt0412142/ (accessed 22 April 2008).
↵ii In the series, it is common for the main characters to refer to each other by last name only (for example, “House” rather than “Dr House”). I will adopt this convention as well.
↵iv This information is from the Internet Movie Database, http://www.imdb.com/Sections/Awards/ (accessed 23 April 2008), and the House M.D. official website, http://www.fox.com/house/showinfo/ (accessed 23 April 2008).