leigh e rich and 3 others the afterbirth of the clinic 1

The Afterbirth of the Clinic

a Foucauldian perspective on House M.D.and American medicine in the 21st century

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ABSTRACT Mirroring Michel Foucaults The Birth of the Clinic (1963), which de-scribes the philosophical shift in medical discourse in the 19th and early 20th centuries,the Fox television series House M.D. illustrates the shift in medical discourse emergingtoday.While Dr. Gregory House is Foucaults modern physician made fleshan objec-tive scientist who has perfected the medical gaze (le regard) and communicates directlywith diseases instead of patientshis staff act as postmodern foils.They provide a para-ble about the state of biomedicine, still steeped in modernity but forced into a post-modern, managed care world. House M.D., however, is more than a mere depiction ofthe modern-postmodern tension that exists in todays exam rooms. It is an indicationof a transition period in American medicine. House M.D. nostalgically celebrates whatonce was and simultaneously questions what currently is, while what is about to be isin the midst of becoming.

Declare the past, diagnose the present, foretell the future; practice these acts.As to diseases, makea habit of two thingsto help, or at least to do no harm.

Hippocrates, Epidemics

*Department of Health Sciences,Armstrong Atlantic State University, Solms Hall 201, 11935 Aber-corn Street, Savannah, GA 31419.

Department of Languages, Literature, and Philosophy,Armstrong Atlantic State University.Foundation Studies, Savannah College of Art and Design.E-mail: [email protected] whom correspondence should be addressed.

Perspectives in Biology and Medicine, volume 51, number 2 (spring 2008):22037 2008 by The Johns Hopkins University Press

Leigh E. Rich,* Jack Simmons, David Adams,*

Scott Thorp, and Michael Mink*

EVERYBODY LIES, Gregory House says of his patients in the televisionmedical drama House M.D. While House means this literally, that clini-cians should regard patients statements with suspicion, the statement also impliesthat every body lies, that bodies, too, may be deceptive. House epitomizes themodern (late 19th- and early 20th-century) approach to medicine in which di-agnostic medicine involves an effort to communicate directly with disease. InSherlock Holmes fashion, the physician searches for the culprit (disease) againstthe backdrop of a world marked by illusion and deception.

In the contemporary (postmodern), managed care system, defined by a pro-liferation of participants in the quest for health, everybody lies means Houseregards not only the patient and body with suspicion, but also the entire med-ical establishment that exercises authority over health care. Having never fullysupplanted the modern, physician-centered approach, postmodern medicineleaves the physician to maneuver in an uncertain medical system that includesHMOs, PPOs, patients, spouses, family members, hospital administrators, phar-maceutical companies, lawyers, legislators, judges, and ethics and oversight com-mittees (Rothman 1991; Starr 1982).

While Michel Foucaults The Birth of the Clinic (1963) clarifies the transitionthat occurred after the French Revolution from a premodern system to modernclinical medicine, House M.D. demonstrates the contemporary transition frommodern to postmodern medicine. Through the irascible, politically incorrectcharacter of Dr. Gregory House, House M.D. diagnoses the cognitive dissonancecaused by conflicting medical ethics: the modern ethic concerned with the elim-ination of disease and the postmodern ethic that defines health as a socially con-structed, subjective experience within a broader sociopolitical context. In thisarticle, we demonstrate how House M.D. dramatizes the modern-postmoderntension in the contemporary medical encounter and forces the audience to ask,What medical paradigm could come next?

Declare the Past: Le Regard

Get him an E.E.G., left and right E.O.G., esophageal microphones. If this thing wants to talk,lets listen.

Paternity (Episode 102)

House M.D.s title character exemplifies the rational and clinically trained prac-titioner that emerged in the 19th and early 20th centuries, as medical discourse,hospitals, and medical education transformed into institutions built on scientificstandards that elevated the authority and prominence of physicians.1 This historyof how the modern, clinical practice of medicine followed the development of


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1In The Birth of the Clinic, Foucault focuses on postFrench Revolution, continental medicine.Thetransformation in medical discourse that Foucault discusses occurred somewhat later in the UnitedStates, during the late 19th and early 20th centuries.

modern science and replaced the premodern medical marketplace, which lackedstandardization and professionalization, has been documented in several medicalhistories (see, for example, Fissell 1991; Illich 1976; Starr 1982).

Of particular interest is Michel Foucaults The Birth of the Clinic (1963), whichdescribes the 19th-century revolution in medicine that altered the physicians rela-tionship not only with patients but also with disease itself. Foucault explains thatthe act of seeing in a modern medical sense requires an understanding of theessential and ideal states of diseasesdiseases as substantive (Illich 1976).This isbecause scientific positivism rejected theoretical speculation and introduced anempirical vigilance and rational discourse to the study of pathology and theclassification of diseases (Foucault 1963, pp. xiiixiv). Germ theory, emerging fromthe work of scientists such as Friedrich Henle, Louis Pasteur, Robert Koch, andFriedrich Lffler, contributed to the idea of empirically identifiable and classifiablesubstantive diseases. From this perspective, diseases represented entities in them-selves, rather than afflictions of particular patients. In this way, modern medicinedistinguished the scientifically knownreal, essential, empiricalform of a diseasefrom symptoms expressed by the presence of a disease in a human body.

But essential disease in its localized state (in an individual patient) remainsimperceptible by normal means, concealed by the body in which it lies.As such,one may observe disease only as a fragmented series of impermanent signssep-arated from their past and disconnected from their futurethat are stalled in amoment of medical observation. To diagnose and identify the real disease, thephysician must hone an appropriate regard that enables him or her to recognizea disease even when it is situated within patients opaque bodies. Thus, onesometimes has to track down a history that is enclosed upon itself and developsinvisibly (Foucault 1963, p. 5). The disease may be understood in its scientifi-cally known form only through the signs and symptoms it presents within ahuman body. Because disease may manifest itself differently with each body, dis-torting the signs and symptoms, it may be said that the human body confoundsthe clinical presentation of disease.

Foucaults notion of le regard is central to the plot of House M.D. Housesmantra that everybody lies, superficially referring to patients, serves as a meta-phor for le regard.Translated from the French as the gaze (as opposed to car-ing or esteeming), le regard indicates a mode of medical perception that en-ables the physician to look through the patient to recognize the disease. Underthe clinical regard, the patient becomes a background of objectivity (Foucault1963, p. xiv). Through le regard, the doctor attempts to communicate directlywith the disease rather than with the patient, who is understood now in his orher particularities only so that these may be abstracted and contextualized inrelation to the physicians medical reading (Foucault 1963, p. 8). Here lies thepremise of House M.D., where Dr. Gregory House, as much detective as doctor,is a master of recognizing disease from whatever, de facto or de jure, sooner orlater, directly or indirectly, may be offered to the gaze (Foucault 1963, pp. 56).

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L. e. Rich, J . Simmons, D. Adams, S. Thorp, and M. Mink

Perspectives in Biology and Medicine

Simultaneously, le regard transforms everything but the disease, and its specificsigns and symptoms, into clinical ephemeranoisy distractions.To catch a fleet-ing glimpse of disease, then, the modern clinician must understand the individ-ual only insofar as to abstract him or her and, thus, better distinguish true signsof a disease from deceptive background noise: unrelated symptoms as well asconcerns, worries, and desires of patients and their families. Only serious med-ical discourse counts in the search for the disease. (See Dreyfus and Rabinows[1983] discussion of Foucaults discursive interests.) House M.D. repeatedlydemonstrates this transformation:

FOREMAN: Shouldnt we be speaking to the patient before we start diagnosing?

HOUSE: Is she a doctor?

FOREMAN: No, but

HOUSE: Everybody lies.

CAMERON [to Foreman, whispering]: Dr. House doesnt like dealing withpatients.

FOREMAN [to Cameron]: Isnt treating patients why we became doctors?

HOUSE: No, treating illnesses is why we become doctors.Treating patients iswhat makes most doctors miserable.

FOREMAN: So youre trying to eliminate the humanity from the practice ofmedicine?

HOUSE: If we dont talk to them, they cant lie to us, and we cant lie to them.Humanitys overrated. (Pilot, Episode 101)

Though perhaps unintentionally, patients physical and mental particularities(and doctors biases) veil disease and, thus, its recognitionor diagnosisin thehuman body. Foucault distinguishes the recognized (reconnaitre) from theknown (connaitre). The recognized refers to the disease discovered in thebody, the known the ideal concept sought through medical investigation. Boththe recognitive and cognitive acts help elucidate the emerging pathologicalprocess, which unfolds concurrently within the patient and apart from thepatient. In other words, the patient is simultaneously important, as the mediumin which the disease is recognized, and irrelevant, as clinical ephemera. Foucaultexplains:Paradoxically, in relation to that which he is suffering from, the patientis only an external fact; the medical reading must take him into account only toplace him in parentheses (p. 8). By describing the patient parenthetically, Fou-cault references Edmund Husserls (1962) phenomenology of the early 20th cen-tury. Like le regard, phenomenology attempted to refine the scientific gaze andbracket irrelevant or ephemeral beliefs and perceptions in order to understandthe thing in-itself. Similar to abstracting the patient, the physician also must sep-arate himself, the observer, from what is observed, creating a gaze that is objec-tive, meticulous, and possesses a passivity that dedicates it to the endless task ofabsorbing experience in its entirety, and of mastering it (Foucault 1963, p. xiv).



Thus, in House M.D., House is indifferent to what any of his patients have tosaywhether they are truthful or deceitfulbecause le regard has rendered pa-tients narratives superfluous (see also Fissell 1991; Kleinman 1988).This is howHouse can do his doctoring on a white board far removed from a patients bed-side. Moreover, the only relevant discourse is the serious speech acts (seeDreyfus and Rabinow 1983, p. xxiv) of the physician, who developed into a pro-fessionalized expert with increasing power and authority in the late 19th andearly 20th centuries.The patient, during this time, became silent. In fact, this ishow House prefers it: when describing a 29-year-old patient who has lost theability to speak, he declares: The one who cant talk? I like that part (Pilot,Episode 101).

In addition to recognizing diseases as substantive and disregarding clinicalephemera, this silencing of the patient completes the medical revolution Fou-cault identifies in The Birth of the Clinic.The subtraction of the patient is cru-cial to modern medicine because the individual lives, experiences, and bodies ofpatients and the individual biases of physicians may conceal the true forms ofdisease even as patient signs and symptoms reveal them.Thus,

the doctors gaze is directed initially not towards that concrete body, that visiblewhole, that positive plenitude that faces himthe patientbut towards intervalsin nature, lacunae, distances, in which there appear, like negatives,the signs thatdifferentiate one disease from another, the true from the false, the legitimatefrom the bastard, the malign from the benign. (Foucault 1963, p. 8)

This is Gregory Houses modus operandi. Together with his Vicodin addiction,which eliminates his own distracting pain, and his political incorrectness, whichdehumanizes his patients, staff, and supervisors, House subtracts the lying bod-ies that surround him in the clinic from his mathematical diagnosis of disease.

House uses the technique of le regard to avoid interacting with human sub-jectspatients, family members, hospital staff, administrators, lawyers, other doc-tors, and even himself. In the television show, this approach provides remarkableresults. Despite his petulance, House is respected for his detached diagnostic acu-men.While he carries le regard to the extreme, all of the physicians in House M.D.practice le regard to some degree.A significant portion of the doctoring done inthe show occurs in the differential diagnosis room, far removed from the bed-sides of patients.Another portion is dedicated to conducting laboratory tests onpatients. Only a fraction of the program depicts any of the doctors talking withpatients.2 This distanced diagnosis, a cornerstone of the modern medicine Fou-

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2See, for example, Paul Starrs (1982) discussion of how scientific medicine and its concomitantdetached technologies such as the microscope, X-rays, and chemical and bacteriological tests madeit possible to remove part of the diagnostic process from the presence of the patient into backstageareas where several physicians might have simultaneous access to the evidence. . . . The collegialexercise of authority strengthened the claim to objective judgment (p. 137).

cault describes, is necessary because the gazing clinician, in order to identify andtreat the ideal disease, imposes meaning on what the patients individual signsand symptoms signify collectively. The collection and interpretation of signs isimportant for two reasons. First, the clinical disease may well share characteris-tics of other illnesses (fever, gastrointestinal distress, etc.). Second, the disease alsomay vary in its degree (a severe case vs. a mild one), yet be manifested by thesame conditions.As House reminds his colleagues in season three,everything isconditional.The modern medical gaze succeeds when it abstracts the real dis-ease from its conditional manifestations.

House M.D. glorifies le regards dehumanizing medical approach when Houseannounces that Humanitys overrated, and when his colleague describes him ashaving a disdain for human interaction (The Mistake, Episode 208). In thisway, le regard detaches the physician from the patient emotionally, linguistically,and morally.The modern physician need not know a patient as an individual, butmerely as an object of rational, scientific inspection. When asked how he cantreat a patient without meeting him, House tells a patients father: It is easy ifyou dont give a crap about him.Thats a good thing. If emotions made you actrationally, well, they wouldnt be called emotions, right? Thats why we have thisnice division of labor.You hold his hand, I get him better (Occams Razor,Episode 103).

The ethic of le regard is the absence of disease, rather than a more speculativenotion of general patient health.The absence or presence of a disease can be em-pirically verified, whereas general patient health (with its sociopolitical associa-tions and underlying subjectivity) cannot be reduced to empirically validatedtruth claims. Armed with an ethic independent of the patients general health,the physician may commandeer the patients narrative, replacing it with a narra-tive that describes the physicians encounter with the disease. Historian MaryFissell (1991) suggests that the modern physician hijacks the patients narrative,filtering the truly medical from the trivial and rephrasing medical storiesin inaccessible, Latinate, professionalized language. Because le regard subtracts thepatients own narrative history, privileging instead the clinical signs of disease, thepatient is transformed from a human, moral agent into an object of medical sci-ence. Foucault explains that during the transition from a premodern medical sys-tem to a modern one, the patient acquired the status of object and the clinicalexperience became that opening up of the concrete individual, for the first timein Western history, to the language of rationality (p. xiv).

Given this transformation, there is no reason the physician cannot experimenton the patient, so long as the physician maintains a view toward accurately diag-nosing and eliminating the disease. For le regard, experimentation on bodiesbecame as indispensable as it is for the natural sciences. The conditions thatunited in the 19th and 20th centuries to transform medicine into a clinical sci-ence made it possible . . . for the patients bed to become a field of scientificinvestigation and discourse and for the patient to be observed in the same way



that we observe the stars or a laboratory experiment (Foucault 1963, p. xv).Thisexperimental approach to medicine is critiqued in House M.D. when hospitaladministrator Lisa Cuddy reprimands House, saying that doctors dont prescribemedicine based on guesses. At least we dont since Tuskegee and Mengele(Pilot, Episode 101). Even the callous House finds this comparison excessive,but the reference reminds viewers that physicians once enjoyed almost absoluteauthority in the medical encounter and often mixed patient care and medical re-search (Rothman 1991).

Nearly every installment of House M.D. portrays House experimenting onpatients (for therapeutic, not scientific or financial, reasons). Experimental testsfacilitate physician-disease communication, as House explains:The more symp-toms we can force out of [a patient], the more tests we can do.The more testswe do the more information we get, the quicker we make a diagnosis(Sleeping Dogs Lie, Episode 218). Consequently, House pretends to botch alumbar punctureto the painful chagrin of the patientto see if this initiates ahypertensive crisis (Deception, Episode 209); ignores a patients DNR orderand intubates him when a treatment causes lung failure (DNR, Episode 109);puts a patient into a medically induced coma so he may continue running diag-nostic tests after the patient refuses to consent (Informed Consent, Episode303); and orders his subordinates to place two similarly ill newborns on differ-ent drug regimens to reveal which disease is the culprit (and craftily uses med-ical privacy laws to justify his approach):

HOUSE:Therapeutic trial, to find the cause of the infection . . .

CUDDY:You cant experiment on babies.

HOUSE: Doctors experiment all the time.

CUDDY: On adults, with their consent.

HOUSE: Fine. Ill get the parents consent.

LAWYER:Their informed consent.They have to know the other kid is gettinga different treatment.

HOUSE: Sorry. Cant do that. It would be unethical for one patient to knowabout another patients treatment.

LAWYER:They have a right to know.

HOUSE: If they know, they wont consent.That defeats the whole purpose.(Maternity, Episode 104)

The medical ethic of le regard allows the physician greater ethical leeway in thequest to diagnose and eliminate disease.This utilitarian approach is expressed byHouse when he explains, I take risks. Sometimes patients die. But not takingrisks causes more patients to die (Detox, Episode 111).

House M.D., however, presents more than a depiction of the gazing doctor andwhat Foucault deems the anatomo-clinical method that has dominated bio-

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medicine since the French Revolution.While House seldom fails to succeed inhis diagnostic quest each week, the show also offers House up for scrutiny, anobject of the television viewers gaze. House may be a hero, but he is a tragichero. He walks with a cane, refuses to dress like a doctor, and is addicted to opi-ates, much like his literary equivalent, Sherlock Holmes.The opening scenes ofthe pilot episode depict the tension, both visually and verbally, between Housesoutmoded form of clinical medicine and the contemporary managed care sys-tem: as Dr. House and Dr.Wilson walk the halls of the hospital, it is unclear tothe viewer who is the authority. Wilson, wearing slacks, a tie, and a white labcoat, carries a patients medical record. House, sporting disheveled street clothesand an unshaven face, clutches a cane. At best, House seems an aging man withan uncertain future, at worst, similar to Karl Marxs (1867) workman languish-ing with the division of labor in capitalistic manufacturing, a crippled mon-strosity (p. 230):

HOUSE:You see that? They all assume Im a patient because of this cane.

WILSON: So put on a white coat like the rest of us.

HOUSE: I dont want them to think Im a doctor.

WILSON:You see where the administration might have a problem with thatattitude?

HOUSE: People dont want a sick doctor.

WILSON:Thats fair enough. I dont like healthy patients. (Pilot, Episode 101)

Houseand the modern system he personifiesis far from healthy. He lackssocial ties; flaunts his drug use before patients, subordinates, and supervisors alike;and, when he becomes the patient, has trouble swallowing his own medicine.

House embodies an antiquated form of medicine, in which the physicianswere the arbiters in the medical encounter, holding sway over hospital manage-ment, medical education, regulations, drug companies, and patients. (See Starr[1982] for a discussion of the consolidation of medical authority and the recon-stitution of the hospital in America between 1850 and 1930; see Rothman[1991] for a discussion of physician-directed ethics during the first half of the20th century.) Physicians no longer enjoy such comprehensive authority, andmuch of their power has been usurped by the patientrediscovered as an auton-omous subject within medicine in the 1960s and 1970sas well as by the vari-ous third parties that have begun to crowd the exam room.



Diagnose the Present: Postmodern Medicine

Gregory House is a symbol of everything wrong with the health care industry.Waste. Insubor-dination. Doctors preening like theyre kings, and the hospital is their own private fiefdom.Health care is a business. Im going to run it like one.

Babies and Bathwater (Episode 118)

The postmodern movement emerged largely in response to the horrors of 20th-century wars. Images of the Somme, Guernica, and Auschwitz provide hauntingtestimony of the consequences of high-tech warfare (see Keegan 1978).Philosophers and artists thus reconsidered the combination of science and indus-trywhich marked the height of modernism and intended to improve thehuman conditionas largely responsible for a science of inhumanity that in-cluded the development of battleships, tanks, machine guns, high altitude bomb-ers, submarines, and biological, chemical, and nuclear weapons.This science alsogave rise to compulsory sterilization laws under the guise of eugenics, Naziexperimentation conducted by physicians on concentration camp prisoners, andvarious ethical issues in clinical research (see Beecher 1966). By mid-century, thelegacy of modern science looked bleak. Philosophical postmodernism reflecteda general suspicion toward a doctrine that seemed prepared to sacrifice the livesof millions in the pursuit of objective truth in every aspect of human life: poli-tics, art, and science (including medicine). Reacting against modernism, post-modernism continues to destabilize concepts such as presence, historicalprogress, epistemic certainty, univocal meaning, and the role of central hierarchyor organizing principles.3

The lure of modernism lay in its promise to produce a single truth of humanexperience based on the objectivity of the scientific method. In contrast to Hus-serl, Martin Heideggers Being and Time (1927) demonstrated the impossibility ofsuch objectivity.Thus, Husserls phenomenological movement, which advocatedbracketing ephemera, gave way to a new hermeneutic that involved a profoundskepticism of the single, objective narrative of modernity. This postmodernmovement accused objective science of concealing racism, sexism, homophobia,elitism, ageism, and ethnocentrism. To address this bias, postmodernism de-manded political correctness, and to offset the authority of modernitys unilat-eral narrative, postmodernism required a proliferation of participants in narrativehistory.

We define postmodern medicine as the reintroduction of the patient andother stakeholders into the medical encounter that has occurred since the 1960sand 1970s. This era has included the publishing of Henry K. Beechers Ethicsand Clinical Research (1966), the end of the 40-year Tuskegee Syphilis Studyin 1972, the adoption of a Patients Bill of Rights by the American Hospital

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3It is generally accepted that postmodernism defies any general or universal definition.This defi-nition uses elements from those provided by Aylesworth (2005).

Association that same year, the passage of the National Research Act in 1974,and the 1976 watershed decision In the Matter of Karen Ann Quinlan that allowedthe parents of a woman in a persistent vegetative state to disable her respirator.No longer merely an incidental to be placed in parentheses in the medical equa-tion, the patient recouped some of the medical decision-making authority (andconcomitant responsibility) the clinician had commandeered with le regard.

The expansion of the medical encounter, however, did not stop with the in-clusion of patients and their families. Financial stakeholders, such as HMOs,PPOs, and hospital administrators, make medical decisions based on the eco-nomics of health care. Pharmaceutical companies influence the prescriptionswritten by physicians and demanded by patients. Concerns over medical justicemean that the lawyers, judges, and juries who adjudicate malpractice casesinform medical protocols and standards. Finally, moral concerns related to par-ticular practices, procedures, and research are deliberated by legislators and vot-ers. But the postmodern skepticism that followed World War II could not fullysupplant the role of the modern physician. Postmodernism may acknowledge thesignificance of every human, but it must also recognize the knowledge and skillof trained professionals. Consequently, medicine in the postmodern era includesthe modern doctor, generating an important tension in contemporary medicalencounters that is dramatized in House M.D.

While Dr. House himself personifies le regard, his colleagueshis boss, Dr. LisaCuddy; his friend, Dr. James Wilson; and especially his three subordinates, Drs.Allison Cameron (an American woman), Robert Chase (an Australian man), andEric Foreman (an African American man)act as postmodern foils.The primaryfunction of these supporting characters is to raise concerns about Houses dis-tanced, authoritarian, scientific style. In the second season, for example, Cameronstruggles with telling a seemingly healthy university employee that she hasmetastatic squamous cell lung cancer and about six months to live.While Housemaintains that Cameron has done everything she needs to do except tell herpatient that shes dying, Cameron soft-sells this conclusion to her patient, whomshe continues to put through medical tests.When the patient wonders why allthe tests have been inconclusive, Cameron replies,Diagnostics is more of an artthan a science (Acceptance, Episode 201). But these comments signify morethan Camerons being too intimate with a patient. A fundamental element ofpostmodernism is the repudiation of objectivity as desirable or possible. Post-modern medicine (even if primarily for legal reasons) openly acknowledges thatdiagnosticsand really, all of medicineis more art than science, or at leastsome combination thereof. Echoing this view, Cuddy admits that reading brainMRIs is not an exact science (Role Model, Episode 117).

House M.D.s writers demonstrate how physicians today share decision mak-ing with postmodern stakeholders.While postmodernism grants patients author-ity, true decision making is often usurped by the new medical bureaucracy,which has concerns of its own. These concerns are expressed when Edward



Vogler becomes chair of the hospitals board of trustees:I want to run this placelike a business. . . .The product that youre selling is good health. It shouldnt bea tough sell (Control, Episode 114).Vogler characterizes Houses exercise ofmedical authority and independence as insubordinate and wasteful. Theaccusation of insubordination reveals the postmodern hierarchy in medicaldecision making to which the physician is now accountable.The accusation ofwaste reveals the new medical ethic that places the financial health of the hos-pital above the health of patients. In the Vogler storyline that spans several epi-sodes, Cuddy references the modern medical ethic and reminds Vogler that sav-ing lives is what hospitals do (Babies and Bathwater, Episode 118), even whileshe acknowledges the postmodern ethic and accepts many of Voglers recom-mendations. House, as the archetypal modernist, regrets this proliferation ofstakeholders, asking, Is the hospital getting out of the dull business of treatingpatients? (Control, Episode 114).

While House may not agree, there are benefits of this postmodern ethic.Theimportance of the artistic, humanistic approach to medicine is well documentedin medical literature. Numerous studies have shown that the White Coat Syn-drome can adversely affect patients vitals, and things such as laughter, positiveattitude, and even prayer can improve medical outcomes (Bennett 2003; Bennettet al. 2003; Brown 2006; Cotton et al. 2006; di Simone et al. 2007; Dusek et al.2003; Engler 2005; Khan et al. 2007; MacDonald et al. 1999; Pitkala et al. 2004;Townsend, Kladder, and Mulligan 2002).

Although House M.D. certainly champions the modern approach to medi-cine, the success of postmodern concern for the patient is regularly on display.In a first season episode, for instance, Foreman leaves the hospital to investigatea dying homeless womans case. He uncovers the mystery of her pastthat shewrecked her car, causing the death of her husband and son, the guilt of whichleads to her psychological collapse and destitution.The episode ends with Fore-man returning to the hospital to comfort her, pretending to be her dead hus-band, forgiving her for the accident, and watching her die with some recoveredpeace of mind (Histories, Episode 110). Through this scene, House M.D. re-minds the viewer that doctoring involves more than simply communicating withdisease. In this case, the disease has prevailed, and so Foreman communicateswith the patient.

House, in contrast, demonstrates his resistance to postmodernism by his polit-ically incorrect behavior toward patients and colleagues. He shows no sensitivitytoward matters of gender, race, or class. He admits he hired Cameron because sheis attractive, Foreman because he has a criminal record, and Chase because hisfather called in a favor. He regularly refers to Foreman as the dark one, com-ments on the breasts and buttocks of Cameron and Cuddy, and belittles Chasesbourgeois upbringing. But even House gets into the postmodern game on occa-sion. In the pilot, he visits a patient who has refused treatment in an effort tochange her mind.Tired of being experimented upon, the woman demands med-

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ical proof of her condition, proof that Houses team produces to her satisfaction.In this instance House and his team develop a special diagnostic procedure thatwill communicate with the patient and address her needs, before administeringthe fairly pedestrian, two-pill-a-day treatment that will cure her disease.

Bedside manner in a postmodern world, as Houses colleagues remind him,has a place in the exam room, even more so now that patients possess greaterdecision-making authority in medical care.This elevated power of patients, how-ever, often reveals the modern-postmodern tension within the physician-patientrelationship. Postmodern patients expect their health care providers to interactwith them and to consider the medical narratives they bring to the encounter.In Poison (Episode 108), for example, the mother of a teenage boy refuses toconsent to Houses treatment, because she believes her sons explanation of howhe became ill while House does not. In a dramatic critique of le regard, the moth-ers skepticism of Houses diagnosis turns out to be correct:

FOREMAN: Dr. House wanted your son to get the medicine he needed. Hewas willing to do whatever it took to make that happen.

MOTHER:The wrong kind of medicine.

FOREMAN: He didnt know that.At the time, it was our only choice.

MOTHER: He would have known if he had listened to me.

FOREMAN: He listened. He just assumed you were wrong.To be honest, thatstrue of most of our patients.

MOTHER:Youre just as pompous and superior as he is!

The reintroduction of the patients voice alters the diagnostic process. Diplomacybecomes a factor in medical decision making, and bedside manner a key elementin establishing a patients trust.

This dimension is exacerbated when the patient possesses some or even sig-nificant medical knowledge.When House becomes the patient, his tune changes.In the storyline that recounts the leg infarction that left House disabled, Stacy,his girlfriend, tries to convince him to consent to amputation.When he refuses,Stacy states that if House were one of his own patients, he would browbeatthem until they made the choice you knew was right.Youd shove it in their facethat its just a damn leg (Three Stories, Episode 121). House, however, insistsits my leg. Its my life.

As a patient, House expects to be a part of the medical narrative, somethinghe denies his own patients.After he is shot in season two, for example, House re-quests information about his surgery and the treatment that was administered tocure his leg pain.They dont like to release patients operative notes, Camerontells him, despite the fact that he is her boss (No Reason, Episode 224).Houses status changes when he is no longer the doctor. In subsequent episodes,Wilson and Cuddy take a similar stance with House, dismissively telling him thatthe pain now returning to his leg is not the failure of the medical treatment but,



rather, the pangs of middle age (Meaning, Episode 301). House insists thathis knowledge of his own body surpasses that of any physician: How can yoube so sure it isnt just a sore muscle?Wilson asks. House responds: Its my leg.Weve known each other a long time (Cane and Able Episode 302).

The shifting of the doctors perspective, from physician to patient, is repeatedto further illustrate the discord in medicine today. In TB or Not TB (Episode204), House refuses to allow a renowned but ill doctor to be part of the diag-nostic process, and when Foreman catches a disease from a patient in Euphor-iaPart 1 (Episode 220), House similarly claims Foreman is not objective.House orders Foreman to simply eat your meals, take your temperature everyhalf-hour and any meds I command you to take. Being a patient, from the mod-ern doctors perspective, means being subtracted from the entire medical processdespite the knowledge one may bring to the table.

But this ideal of subtraction is no longer possible in a postmodern world.While House considers most of his patients idiots, the postmodern patient isoften aware of modern medicines shortcomings and failings. Even a teenagepatients girlfriend in Occams Razor (Episode 103) is not placated or dupedby the evasiveness of the physicians:

MINDY: His glands? What does that mean?

CHASE:We have a few theories were working on.

MINDY:You mean you dont know.

PATIENT: Mindy.

MINDY: Im just saying, if they knew they wouldnt be testing you, theyd betreating you.

FOREMAN:Yeah, well, thats the way it works. First we find out what it is,then we get you better.

One finds many examples of these smart postmodern patients in House M.D.Their presence provides a commentary that undermines Foremans modernistassertion in the above excerpt: the scientific cause-and-effect approach may notbe infallible in health care.Ailments often have more than one cause, which mayor may not be knowable, and treatments and cures, whether accessible or afford-able, do not always exist.

On the other hand, postmodernism has produced its own predicament.Whileit has attempted to revive the humanity in medical practice, the danger is that itmay have introduced too many stakeholders.With strangers crowding the post-modern exam room and vying for attention, control, and bottom-line profits(Rothman 1991), health care practitioners have diminished authority and mini-mal interaction time, and often must treat patients more like automobile parts ona Ford assembly line. House, for all of his modern rhetoric and postmodern inad-equacies, is anything but an automatic motor of a fractional operation (Marx1867, p. 231). Le regard may place patients in parentheses, but its primary purpose

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is to silence clinical ephemera that obscure disease and, thus, treatment. For 2,500years,Western philosophy and science have struggled to eliminate the obscuringpower of what Plato called doxa, Nietzsche called the herd, Heidegger calledthe they, and Kierkegaard called the crowd:The noisy, voting crowd is un-truth, because it ignores the individual for the sake of the crowd (Kierkegaard1975, p. 94). House ignores the crowd for the sake of the individual.

The postmodern state of American biomedicine champions clinical ephem-era, creating indecision and misplaced agency within the medical encounter. Byallowing greater participation in medical decision making, practitioners mustcollaborate with patients and other third party stakeholders who may lack theknowledge necessary to make an informed decision. Foreman offers a primeexample in Paternity (Episode 102), when he tries to obtain consent from theparents of a teenage boy:Well, the antivirallook, Im sorry. I can explain thisas best as I can, but the notion that youre going to fully understand your sonstreatment and make an informed decision isis kind of insane. Heres what youneed to know. Its dangerous. It could kill him.You should do it. Bemoaning thedilemma inherent in informed consent, Foreman explains: We expect familymembers to make decisions about their loved ones after a 10-minute briefingthat were agonizing over even with years of medical experience (EuphoriaPart 2, Episode 221).

Relying instead upon le regard, House rarely agonizes. Approaching illnessesscientifically, he bases his diagnoses on the best available evidence and his treat-ments on his diagnoses.This methodology leaves little cause for either agonizingor the postmodern demand for patient participation.

Foretell the Future

Truth begins in lies.

Pilot (Episode 101)

That the truth begins in lies is Houses recognition that real knowledge must beabstracted from the lies of the postmodern everybody. Painted as both hero andantihero who acts the same no matter the situation, the character of GregoryHouse enables House M.D. to explore whether a modern clinical physiciancanor shouldsurvive in a postmodern world.

This modern-postmodern tension in House M.D. unfolds before its viewers,using the power of television to simultaneously create distance from and gener-ate an intimacy with the patients and their signs, symptoms, and diseases. Theviewer, like one of Houses staff, is invited to participate in the practice of leregarda fellow investigator staring at Houses white board, trying to identify thedisease.The patients are objectified by the shows physicians, with the help of leregard and biomedical technology such as X-rays, CAT scans, and MRIs. Patientsalso are invaded by the camera as it moves through their bodies in search of thedisease.The viewers location, utterly separated from the patient and the clinical



ephemera, reifies the modern notion that the objective viewing is knowing.In this way, the viewer, sitting at home watching television, becomes the ultimateHouse.

House M.D. uses visual techniques to emphasize the importance of le regard.In the pilot, for example, the opening scene illustrates the power of a clinicalgaze.The camera follows Rebecca, a 29-year-old female soon to be Houses firstpatient, as she travels to work. Clearly anxious, she is seen riding a crowded citybus and then crossing an encapsulated pedestrian causeway to reach her destina-tion, the school where she teaches.While discussing with colleagues and studentshow she spent her weekend, Rebecca dramatically falls to the floor, convulsingviolently.The images and dialogue of this scene, like Houses mantra that every-body lies, have double meanings. Rebecca is infected with Taenia solium, a tape-worm found in pork. For the parasite to cause disease in a human body, it has toenter that body and be transported to a susceptible site, similar to Rebeccas useof mass transit. T. solium first enters through the mouth, then switches modes oftransportation in the digestive track, and finally rides the circulatory system tothe brain.A viewer practiced in le regard would be able to diagnose Rebecca fromthese artistic signs and symptoms, just as House does with the clinical ones.Moreover, the dialogue misdirects the viewer as Foucault says patients bodies do.The dialogue of the opening scene hints that Rebecca spent the weekend witha new paramour. In a premodern medical system, such promiscuity might bedeemed the cause of her disease; however, in the modern system that Foucaultdescribes, it is only the substantive taeniasis that is the culprit. As with all ofHouse M.D.s patients, Rebeccas pre-hospital life is abstracted at the top of theshow, and the viewers relationship with her, just like hers with House, ends oncethe disease is diagnosed.

House M.D. is similar to other medical programs, all of which offer a look atthe medical world and at the public and private lives of medicines key players.And although they are intended as entertainment, such shows can affect thepractice of medicine (Chory-Assad and Tamborini 2003). For example, research-ers Michael Pfau, Lawrence J. Mullen, and Kirsten Garrow (1995) have exam-ined how fictional medical programs influence public perceptions of physiciansby exploring what sociologist Erving Goffman has described as the front re-gion and backstage domains of professionals.They found that, while

Limiting public access to backstage is a precondition to maintaining trust in professionals . . . todays programs often probe deeply into the physicians backregions, revealing occasional uncertainties in diagnoses and mistakes in treatment,and exposing unflattering personal traits (adultery, arrogance, and avarice, toname a few). (p. 444)

Thus, Pfau and colleagues conclude, no longer are television physicians superdoctors in terms of their integrity, kindness, professionalism, or standing in thecommunity.This is hardly surprising, considering postmodernism candidly ques-

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tions such romanticized and one-sided depictions of anyone, particularly thosein positions of power.A quick review of recent medical shows provides evidenceof Pfau et al.s conclusion: physicians portrayed in programs such as M*A*S*H,Trapper John, M.D., Chicago Hope, ER, Scrubs, and Greys Anatomy are far from per-fect, as viewers witness how doctors personal and professional lives intermix.

However, House M.D. holds not just the medical realm up for inspection butalso medical philosophy. Houses personification of le regard remains untouchedby his personal and professional strengths and shortcomings. He regularly ignorescomments by patients and colleagues about his rough demeanor, his lack ofhumility, and even his success in diagnosing disease.Whether House succeeds orfails, the audience never doubts the efficacy of his method. Even when le regardfalters, as it often may, viewers never suspect the method itself of human frailtyor avarice. This is the power of an objective method. Although the viewer isdrawn into Houses personal life, as with any medical program, House M.D. per-petually reminds the viewer that Houses drug addiction, sexual deviance, andinability to maintain healthy relationships with other adults are irrelevant to hispractice of medicine.At this level, House M.D. extols the virtue of methodology,reminding us that the backstage personalities Pfau, Mullen, and Garrow haveuncovered in other medical shows reveal nothing but clinical ephemera, of noconsequence to the practice of objective medicine. Houses creator and produc-ers have fashioned their title character in this way on purpose.As executive pro-ducer Paul Attanasio (2006) explains: What do doctors really think of theirpatients? What does a doctor say when he leaves the room? And just make it suchthat he says that while hes in the room. The collapsing of Houses front andback regions through his relationships with patients reveals only his consistent,modern medical ethic: to identify and eliminate the disease.

In a postmodern world, however, the modern medical ethic creates tensionwithin the medical encounter as well as dissatisfaction for physicians and patientsalike.Although medical schools continue to train physicians in le regard, physiciansare expected to behave according to a postmodern ethic that may place them atodds with that regard (for example, recognizing patient autonomy, sharing author-ity with various third parties, and managing their practices using a businessmodel).This expectation is proving too complex.The inclusion of a broad spec-trum of lay participants in health care works at cross-purposes with the scientificgoal of disease identification and elimination. This duality produces an ethicalcontradiction in the American medical system. This contradiction may be re-sponsible for other contradictions (symptoms), perhaps explaining how Americanmedicine offers the finest care in the world but struggles to provide basic healthcare to a large and growing number of its citizens.Although Dr. Gregory Houseplays the role of hero, House M.D. reminds us that this problem is severe, mortalfor some, and that a simple return to modern medicine an unlikely and per-haps undesirable solution. Still, in this new millennium nothing less than theethic of medicine is at stakewhether medicine remains fundamentally a natu-



ral science that treats disease or a human science that services a broader sociopo-litical purpose.

In the meantime, shows such as House M.D. will continue to be a mirror laHamlet, reflecting the signs and symptoms of Americas ailing health care system.We search for clues that illuminate the causes of its disease, and we seek coursesof action. But, like Gregory House and his colleagues, we pursue the very thingFoucault (1963) suggests we may never possess: the ideal configuration of thedisease [in which it] becomes a concrete, free form, totalized at last in a motion-less, simultaneous picture, lacking both density and secrecy (p. 9).

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leigh e rich and 3 others the afterbirth of the clinic 1

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