Hobsonphile (hobsonphile) wrote,

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More from the House Essay of Doom:

(Posted publicly to allow outside response.)

Previously discussed: the Stacy arc.

In this segment, I tackle Vogler (under the working sub-head: “The Problematic Quest for Moriarty - House and His (Imperfectly Written) Antagonists”):

“Gregory House is a symbol of everything wrong with the health care industry: waste, insubordination, doctors preening like they're kings and the hospital their own private fiefdom. Health care is a business. I'm gonna run it like one.” – Edward Vogler, Babies and Bathwater

(Note: Spoiler warning for the end of the first season.)


When pharmaceutical magnate Edward Vogler becomes chairman of the board at Princeton-Plainsboro in the first season in exchange for a gift of $100 million, House’s reaction is one of instant, visceral distrust. Citing Vogler’s obvious financial interests, he warns Cuddy in Control that patient care will be compromised with Vogler at the helm. “Are we a pharmaceutical company?” he challenges. “We’re gonna wind up pressuring desperate patients into choices that are bad for them, good for us.” Vogler, meanwhile, immediately despises House upon their first encounter and, citing House’s consistent violations of hospital protocol, announces his intent to bring the head of Diagnostic Medicine to heel. What results is a power play that leads to Cameron’s resignation, Wilson’s discharge from the board, and, ultimately, the loss of Vogler’s massive donation, a sacrifice that leaves Cuddy questioning whether House is worth the price.


The larger issues that arise within the admittedly flawed Vogler arc are far from trivial. The rarefied sphere in which medicine resides in the public moral consciousness does not easily accommodate the economic reality of modern American healthcare, a reality in which doctors must contend daily with limited resources and industry pressure. Here, House vocalizes the anxieties engendered by such a conflict and, in the process, exhibits an odd kind of idealism that, as we shall soon see, is one of the signatures of his mind. Indeed, there is something distinctly noble in House’s wholesale refusal to be threatened or bought. When House publicly embarrasses Vogler at an evening event by first claiming that Vogler’s new drug is, medically, virtually identical to an older one and then sarcastically applauding Vogler’s business acumen (Role Model), one feels a very real, if short-lived, sense of satisfaction. In the real world, medical journals like The Journal of the American Medical Association require full financial disclosure for every article submitted for a very good reason, and there is no doubt that Vogler’s attempt to forcibly use House’s reputation to promote his company’s product would, in a real-world context, result in universal opprobrium.


It would be a mistake, however, to dismiss Edward Vogler completely, for in more than one respect, he is correct about both Gregory House and the current business of medicine. And here is where the primary weakness of this storyline really shines through: In the end, Vogler is not permitted to argue compellingly for House’s obsolescence. Instead, he becomes obsessed with emphasizing his own power. But an anachronism House is. In The Medical Science of House, M.D., Dr. Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, calls House a “Dr. Schwarzenegger-Welby,” referencing, of course, the idealized solo practitioner of a television era gone by. I believe a comparison to turn-of-the-century fictional physician Dr. Martin Arrowsmith, creation of author Sinclair Lewis, is more apt. The hero in Arrowsmith is eerily recognizable: he sneers at the minutiae of general practice; he sanctimoniously derides financial and political reward; he is frustrated by the continuing superstition of the general public; he virtually abandons his wife to pursue his research; and he is sadly deficient in basic social niceties.


But Dr. Arrowsmith is also a product of his time – a symbol from a transitional period in medicine in which doctors were actively seeking legitimacy as full-fledged educated professionals en masse for the first time. Not overly long before the publication of Arrowsmith, physicians in the United States were still basing their treatments on Galenic theories, but the nineteenth and early twentieth centuries saw the importation of the European style of medical education and the beginnings of truly scientific research medicine in the New World. In such an atmosphere, formally educated physicians had an incentive to tout the superiority of their knowledge and decry “quackery.” Over several decades, the previously de-centralized industry of American medicine transformed into an institutional (and, for much of the 20th century, discriminatory) entity headed by white-collar elites. Circa 1925, Medicine-as-Science was in ascendance, and it was generally assumed that such science should be left to the professionals. The arrogant Arrowsmith could thus be accepted as a hero.


Today, however, medicine is a team sport – a team that includes doctors, nurses, technicians, insurance companies, public health officials, and the patients themselves. “House is some kind of iconoclastic solo guy who can do it all. But there isn’t any such person,” says Dr. Caplan. “You have to have social skills to work in modern medicine.” This assessment matches Edward Vogler’s inchoate instinct. Rightly, he views House’s refusal to wear a white lab coat as a symbolic expression of House’s overall disrespect for hospital protocol. Rightly, he recognizes that medicine exists in the same world of trade-offs and hard choices as do other essential goods and services, and while his single-minded obsession with House’s department in particular does nothing to serve his position, the fact that he demands that physicians justify their expenditures does not in itself make him inherently evil. In truth, Vogler’s rule-oriented concerns can put him on the side of good – and House’s refusal to consider same is as much tunnel vision as it is idealism.


In Control, for example, House deceives the transplant committee to acquire a new heart for his bulimic patient. Granted, on the (long) list of House’s ethical violations, this one is certainly the most hesitant. House’s awkward non-admission to Wilson – and his demand that his patient beg for her life - underscores his acknowledgement that he is making a choice that will favor one human being over another. Still, his final decision, while in some senses respectable, can only be unambiguously championed in a utopian world with no consequences and no limits. House is not the only doctor at Princeton-Plainsboro, and his patients are not the only patients, either at PPTH or in the state of New Jersey. It’s certain that his lie before the transplant committee took a chance at life away from another worthy patient. That’s why transplant committees in hospitals nationwide depend upon qualifying and disqualifying criteria. There are simply too few organs to go around. This is the big picture – something House consciously decides to put aside in all situations in which such larger concerns conflict with the interests of his patients.


On an individual level, one can argue that, yes, House is often, despite his own best efforts, a compassionate physician in the truest sense (shocking, I know – but I promise it will all make sense in the end), but on a collective level, he just as often falls short.  When Vogler rails against House’s “preening” - or levels the charge that House is not a team player - he is not in the wrong.

Next up: Tritter!

Tags: house md

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