More Medical Ethics Stuff

Dr. Mac's thread inspired me to add on to a topic I'd raised earlier about Dr. House's approach to medical ethics (see "Medical Ethics a la House," below).

In "Control," House seemed to be acting a bit unlike the amoral misanthrope we know and love. He uttered the phrase "unethical" twice (I think), and he wasn't joking. Both Cuddy and Wilson called him on this peculiarity, so we know it wasn't just a writing glitch. And his behavior toward his patient, while far from warm and fuzzy, was more personal than usual. He seemed almost like those "good guy" docs on ER, who risk themselves to buck the system in order to help their charges. What's up with that?

I think this episode gave us some new information about House's ethical views. What was it that House deemed unethical? Medical research. Patient trials. Well, on the face of it, that's just silly. As Cuddy pointed out, medical research (if done properly) is not evil. It saves lives. Moreover, House himself uses trial and error on his patients. In a sense, each one of them is an experimental subject. House mentioned that changing the mission of the Hospital could result in pressuring desperate patients to participate in trials. This might result in not getting truly free and informed consent. But, again, these values aren't high on House's list. He is not above pressuring patients or their families to agree to treatment. And, much of the time, he seems to regard informed consent as a mere formality.

So, what is House really objecting to? Not medical research per se, but the conflation of medical research and medical treatment. What is the difference? They have different goals. Medical research aims to benefit others (although it may also benefit the patient himself); medical treatment aims to benefit the patient (although it may, incidentally, benefit others as well). It is fine for drug companies or research establishments to conduct experiments. It is even fine for doctors within hospitals to perform research, as long as they are clear about how it differs from rergular patient care. But it's not fine to covertly transform a hospital into a tool to find the cure for cancer. That would, as House put it, "kill" the hospital, as a hospital.

House doesn't say all that, but he shows it through his actions. He is normally quite utilitarian in his ethical decisions -- he believes one ought to do what brings the best results, making occasional exceptions out of respect for autonomy. But, on a utilitarian analysis, it would probably be hard to justify giving his bulimic patient one of a limited number of transplantable organs. It is reasonable to believe that another patient on the waiting list, one who does not have an eating disorder, might have better results with the donor heart than House's patient will.

Yet House firmly refuses to take the "big picture" approach. That is the job of the transplant committee. HIS job is to do what is best for his patient. And that's what sets him apart from a researcher. House may not like his patients, but he is THEIR doctor. His goal is to cure them. Not cure cancer.

OK, I know I oversimplified the difference between research and regular medicine. But what do you think?

Medicine: A Spectator Sport?

Some thoughts I had....

You remember the scene from Occam's Razor: Foreman threads a Swan-Gantz catheter through the heart and into the pulmonary artery of the patient, Brandon, prior to surgery. On the other side of a glass wall, Mom, Dad, and Fiancée watch the procedure. Things go awry: Brandon's BP drops, his heart stops. Cameron closes the curtains as the Ducklings break out the defibrillator.

This brings up an interesting question: would the family be allowed to watch a procedure like a heart catheterization? Should family members be allowed to watch?

I was reminded of a case from many years ago, when I was a medical resident in a southern California trauma center.

One evening, I ran the code on a 12-year-old boy who had been hit by a truck while riding his bike home from school. He coded just after arriving in the emergency room and we couldn't bring him back. The ER staff worked for 45 minutes without getting a sinus rhythm. I pronounced the time of death...and then I noticed the man in the corner.

He was just standing there, against the wall, out of the way. He wasn't wearing scrubs or other medical garb and, when I noticed the tears, it hit me: this was the boy's father. He had been present the whole time. He had seen it all: the code, the attempts to resuscitate, the final call.

The father was devastated, of course, but he later wrote me a letter in which he expressed his gratitude for being there at the end - it gave him closure to just be present when his son died and he knew the ER staff did everything we could - he had witnessed this.

Should the father have been allowed to stand there, to watch his son be intubated, bagged, shocked, and pumped full of drugs all for naught?

some thoughts on House v. Holmes....

... from emerelin at the house_md lj community.

Not having much success at isolating a sample quote. Just go read it, it's cool.

Template change

Just fooling around -- I liked the look of this one a bit better. In the future I'm going to customize it to make it more House-relevant.

Liveblogging: Omar Epps on Regis and Kelly

9:09 AM: I never watch this show and now I see why. I think my ears would start bleeding if I had to watch it every day. So far all Reege and Kelly have done is sit around, drink coffee, and babble. Kelly has informed us that her jacket is not orange, it's SAFFRON. What's with the montage of baby pictures behind them?

9:13: Would you hurry up and get Omar on already? No, they are gushing about the "Miami Vice" movie. Apparently it's going to star Colin Farrell. They're holding up a picture to the camera. Farrell needs to study the show -- instead of looking all cool and tropical, he just looks like a guido. Ewww.

9:15!!! They're announcing Omar! no, wait. Commercial break? No, they're giving away a minivan to some woman in Fort Wayne named Tammy. Kelly seems to think that Fort Wayne is in Manitoba or something like that. The movie is "9 to 5." Fort Wayne woman gets the Pontiac and an extended service contract. That's sexy. The announcer makes a point of saying, "We're covering all the taxes!" Not like that cheap wench Oprah.

9:19. Break to commercial. The Bachelorette's on first. Vermin. Are they going to make me wait till the end of this horrible show?

My dear late grandmother -- God rest her querulous soul -- used to complain that she never watched Regis and Kathy Lee because Kathy wore high heels when she was pregnant, and she wore them every day!

Now they're advertising that "Robots" movie. I have a personal vendetta against the makers of that movie -- my four-year-old is longing to see it and I'm not going to take him because the movie seems to be 95% butt jokes and I really don't need to be putting up with that kind of thing.

9:22. Bachelorette. I'm going to go work on the ficblog for a while.

9:27: Commercial break. Did it really take the Bachelorette that long to figure out that a guy named "John Paul" is probably named after the Pope? No wonder she needs a reality show to set her up. Duh. Omar's next!!!!!!!!!!!!

9:30: Here he is!!!!!!!!!!!

Omar's wearing a knit cap, a dress shirt under a patterned sweatshirt (pattern: big fancy crest, words "New Republic", and sneaks. Dark colors head to toe. His sneaks look like Converse All-Stars. He grew up in Brooklyn, talks about the restaurants (likes Jamaican and Italian), has two little girls, calls his nephew every morning to tell him to go to school (how cute!). Did not enter his daughter into Reege and Kelly's beautiful baby contest.

Uh-oh -- UPS man. Gotta get the door. Commercial break.

9:36: Omar's back. Reege talks about the great ratings. Omar: On this network, this is the biggest show by far. Talks about playing a doctor on ER. "It's a pretty good role." Tells Reege, "I want to rule the world!" (in an ominous whisper.)

They're going to show a scene!!!! Omar on playing Dr Foreman: "We see things from different angles, but we have the same goal." "House has the WORST bedside manner!" "Would you want a nice doctor, or someone who knows what he's doing?"

Scene from DNR (The post-intubation "what's wrong with you" scene)

Wild clapping! Bye bye Omar -- ??!! NO, NO, STAY, tell us more about the show, about working with Hugh Laurie! NOOOOOOOOOOOOOOOOOOOOOOO!

*snif* Bye bye Omar. Break's over. They're talking to some scary-looking woman about the Oscars. *click*

Just saw "Fidelity" for the first time...

OK, in my fic "Loyalties" (link to the right) I suggested that Wilson and Cuddy were in cahoots on the bet in "Detox."

I threw in a detail about the green tie just for fun. At that point I hadn't seen "Fidelity."

But I just finished seeing this ep for the first time. I walked straight from the DVD player to the computer. And I am convinced: That story about the poor sad oncology nurse was baloney. Wilson was wearing that green tie... for Cuddy.

I'll post my evidences later. I just had to say it.

UPDATE ("Fidelity" spoilers):

I think they were giving us a couple of clues in "Fidelity."

First, in the "green tie" scene in the clinic. House and Wilson have come out of the exam room:

Wilson: Well. That’s what breasts look like.

House: Is a lie a lie if everybody knows it’s a lie?

Wilson: Well, if a tree pretends to fall in a forest… House, come on, they're breasts. They're a birthday present, not a philosophical treatise.

House: Lie number one, she did not do that for her husband, she did that for herself. She thinks if she looks different, she'll be different.

Wilson: No, she thinks if she looks different, she'll be more attractive, which, I have to say…

House: Not to her husband. Cosmetic surgery is so that everyone else will look at us differently. Same reason you're wearing that tie.

Wilson: Well exactly, that was going to be my next point.

House: Last three months, same five ties. Thursday should be that paisley thing.

Wilson: It's a gift from my wife.

House: No it's not. Julie hates green. You bought that yourself. You want to look pretty. At work. [singsong] Wilson's got a girlfriend…

Wilson: Stop! Stop. I don’t.

And at that exact moment, the camera cuts not to House for his retort -- but to Cuddy.

Coincidence? Probably. But later in the same episode, Wilson calls on House in his office. They discuss the case, and then House asks...

House: ...So, what's her name? When do I get to meet her?

Wilson: There's nobody. Give it up.

House: Your lips say no, your shoes say yes.

Wilson: Well, they're French. You can't trust a word they say.

House: Solid, yet stylish. A professional woman would be impressed. I'm thinking accountant, actuary, maybe. It's somebody in the hospital. Patient? No, chemo's not sexy. Daughter of the patient? She would certainly have the neediness you need.

Wilson: I'm not gonna date a patient’s daughter.

House: Very ethical. Of course, most married men would say they don’t date at all.

Wilson: There was no date! I had lunch with one of the nurses. It's her first time in an oncology unit and she's having a tough time, emotionally.

House: Perfect.

Wilson: I wanted to be nice. That’s all. I mean it.

House: You always do. It's part of your charm.

And at that precise moment, who walks in but... Cuddy again. There's also a little joshing where House teases Wilson about Cuddy being jealous of the well-endowed patient. But during that scene, while House is talking, look closely at the way Wilson's looking at Cuddy. (sorry, couldn't find a cap.)

Looking at it in print, it seems like a stretch, but the timing of the scenes just struck me. BOTH of the times House is teasing Wilson about his "girlfriend", Cuddy walks in. I think they're dropping us a hint.

Also, what better time to start hinting at this subplot than an episode about fidelity and infidelity?

Finally, Wilson points out that you can't trust a word his shoes say. And the next episode was supposed to be "Sports Medicine," in which Wilson gets caught in a lie. About having dinner. With a (different) woman. Later, in "Detox," we learn that he was in cahoots with Cuddy about the bet -- and he is soooo confident House will never believe he came up with the idea. So what else is he prepared to deceive House about?

That's what I'm seeing in the tea leaves.





Thanks to Celebmir for the transcript.

Damned if You Detox II

Some quotes from St Augustine of Hippo....

"Let us understand that God is a physician, and that suffering is a medicine for salvation, not a punishment for damnation."

"Question the beauty of the earth, the sea, the air distending and diffusing itself, the sky... question all these realities. All respond: 'See, we are beautiful.' These beauties are subject to change. Who made them if not the Beautiful One who is not subject to change?"

"Late have I loved you, O Beauty ever ancient, ever new, late have I loved you! You were within me, but I was outside, and it was there that I searched for you. In my unloveliness I plunged into the lovely things which you created. You were with me, but I was not with you. Created things kept me from you; yet if they had not been in you they would have not been at all. You called, you shouted, and you broke through my deafness. You flashed, you shone, and you dispelled my blindness. You breathed you fragrance on me; I drew in breath and now I pant for you. I have tasted you, now I hunger and thirst for more. You touched me, and I burned for your peace."

"Our life and our death are with our neighbor. "

"You made our hearts for You, O Lord, and they cannot rest until they rest in you."

Damned if You Detox

cross-posted to Taru's site

Wilson to House: "You're miserable! And you're afraid to face yourself."

Hmmmm... miserable. And where have we heard that before? In the chapel, when Sister Eucharist is sparring with House. She called it months ago (and House blew her off.)

I am wondering if Sister E is a mirror image to House. In some ways, they're alike. He cares for the sick; she is the infirmarian for the sisters -- kind of the "school nurse" for the monastery. They're on the same wavelength about the source of Sister A's present illness -- they both think it's of natural origin (as opposed to supernatural.) House even indirectly quotes Sister E later in the episode: Sister E remarks, If I break my leg, I believe it happened for a reason. I believe God wanted me to break my leg. I also believe He wants me to put a cast on it. Later House tells Sister A, I know you believe in God but I bet you still look both ways before crossing the street. House says "everyone lies;" Sister E thinks Sister Augustine has been malingering all these years (and in doing so gives a big whomping clue to Sister A's illness.) They both end up in the chapel, though for very different purposes, where they even eat together, breaking a candy bar together instead of bread (*ahem* that would be bread as in Eucharist.) House starts the probing questions game -- let me provoke you into revealing more about yourself -- and Sister E plays the game right back.

Of course, mirror images are backwards. He doesn't believe (or says he doesn't); she does, and in a tough, practical way. He goes to the chapel to distract himself with TV; she goes to center herself in prayer. When House calls Sister E on her "four out of seven" sins; she doesn't get defensive; she is probably well aware of her faults. But when she calls out House, he rudely breaks off the conversation so he can get back to distracting himself.

The sisters' names are also interesting. Sister Pius is easy. She has a simple, almost credulous faith. Pius = Pious.

Sister Augustine is named after the great St Augustine of Hippo, who led a wild life as a youth (including fathering a child out of wedlock) but after years and years finally came to belief.

Sister Eucharist has a weird name in the sense that I cannot imagine a nun in real life taking this name. And I am still mulling over what it means to the episode. In Catholic theology, the great mystery of the Eucharist is Jesus Christ really and truly present -- the faithful can see Him and touch Him. Sister E looks for the natural explanation first, but she is named for an astounding mystery. Maybe it's because she sees God expressing Himself in ordinary events that require an "ordinary" response from her. She doesn't need special effects like stigmata to rock her world -- she sees "signs and wonders" in the ordinary.

Sister P is simple, naive, almost gullible. Sister E is much more tough-minded and practical. Sister A seems to have the golden mean between these two extremes -- her faith is solid and child-like in the sense of trusting, not childish in the sense of uneducated. She approaches faith with both the childish trust of Sister Pius and with the practicality of Sister Eucharist.

You can see this visually in that amazing shot of Sister A in bed, with her two sisters in prayer at her right and left hand. The triangular composition of the shot reminds me of medieval sacred art.