The Afterbirth of

the Clinic
a Foucauldian perspective on House M.D.
and American medicine in the 21st centur y

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

Scott Thorp, and Michael Mink*

ABSTRACT Mirroring Michel Foucaults The Birth of the Clinic (1963), which describes 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 emerging
today.While Dr. Gregory House is Foucaults modern physician made fleshan objective scientist who has perfected the medical gaze (le regard) and communicates directly
with diseases instead of patientshis staff act as postmodern foils.They provide a parable about the state of biomedicine, still steeped in modernity but forced into a postmodern, managed care world. House M.D., however, is more than a mere depiction of
the modern-postmodern tension that exists in todays exam rooms. It is an indication
of a transition period in American medicine. House M.D. nostalgically celebrates what
once was and simultaneously questions what currently is, while what is about to be is
in the midst of becoming.
Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make
a 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 Abercorn Street, Savannah, GA 31419.
Department of Languages, Literature, and Philosophy, Armstrong Atlantic State University.
Foundation Studies, Savannah College of Art and Design.
E-mail: Leigh.Rich@armstrong.edu.To whom correspondence should be addressed.

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Gregory House says of his patients in the television

medical drama House M.D. While House means this literally, that clinicians should regard patients statements with suspicion, the statement also implies
that every body lies, that bodies, too, may be deceptive. House epitomizes the
modern (late 19th- and early 20th-century) approach to medicine in which diagnostic medicine involves an effort to communicate directly with disease. In
Sherlock Holmes fashion, the physician searches for the culprit (disease) against
the backdrop of a world marked by illusion and deception.
In the contemporary (postmodern), managed care system, defined by a proliferation of participants in the quest for health, everybody lies means House
regards not only the patient and body with suspicion, but also the entire medical establishment that exercises authority over health care. Having never fully
supplanted the modern, physician-centered approach, postmodern medicine
leaves the physician to maneuver in an uncertain medical system that includes
HMOs, PPOs, patients, spouses, family members, hospital administrators, pharmaceutical companies, lawyers, legislators, judges, and ethics and oversight committees (Rothman 1991; Starr 1982).
While Michel Foucaults The Birth of the Clinic (1963) clarifies the transition
that occurred after the French Revolution from a premodern system to modern
clinical medicine, House M.D. demonstrates the contemporary transition from
modern to postmodern medicine. Through the irascible, politically incorrect
character of Dr. Gregory House, House M.D. diagnoses the cognitive dissonance
caused by conflicting medical ethics: the modern ethic concerned with the elimination of disease and the postmodern ethic that defines health as a socially constructed, subjective experience within a broader sociopolitical context. In this
article, we demonstrate how House M.D. dramatizes the modern-postmodern
tension in the contemporary medical encounter and forces the audience to ask,
What medical paradigm could come next?

VERYBODY LIES,

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 practitioner that emerged in the 19th and early 20th centuries, as medical discourse,
hospitals, and medical education transformed into institutions built on scientific
standards that elevated the authority and prominence of physicians.1 This history
of how the modern, clinical practice of medicine followed the development of
1 In

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

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modern science and replaced the premodern medical marketplace, which lacked
standardization and professionalization, has been documented in several medical
histories (see, for example, Fissell 1991; Illich 1976; Starr 1982).
Of particular interest is Michel Foucaults The Birth of the Clinic (1963), which
describes the 19th-century revolution in medicine that altered the physicians relationship not only with patients but also with disease itself. Foucault explains that
the act of seeing in a modern medical sense requires an understanding of the
essential and ideal states of diseasesdiseases as substantive (Illich 1976).This is
because scientific positivism rejected theoretical speculation and introduced an
empirical vigilance and rational discourse to the study of pathology and the
classification of diseases (Foucault 1963, pp. xiiixiv). Germ theory, emerging from
the work of scientists such as Friedrich Henle, Louis Pasteur, Robert Koch, and
Friedrich Lffler, contributed to the idea of empirically identifiable and classifiable
substantive diseases. From this perspective, diseases represented entities in themselves, rather than afflictions of particular patients. In this way, modern medicine
distinguished the scientifically knownreal, essential, empiricalform of a disease
from symptoms expressed by the presence of a disease in a human body.
But essential disease in its localized state (in an individual patient) remains
imperceptible by normal means, concealed by the body in which it lies. As such,
one may observe disease only as a fragmented series of impermanent signsseparated from their past and disconnected from their futurethat are stalled in a
moment of medical observation. To diagnose and identify the real disease, the
physician must hone an appropriate regard that enables him or her to recognize
a disease even when it is situated within patients opaque bodies. Thus, one
sometimes has to track down a history that is enclosed upon itself and develops
invisibly (Foucault 1963, p. 5). The disease may be understood in its scientifically known form only through the signs and symptoms it presents within a
human body. Because disease may manifest itself differently with each body, distorting the signs and symptoms, it may be said that the human body confounds
the clinical presentation of disease.
Foucaults notion of le regard is central to the plot of House M.D. Houses
mantra that everybody lies, superficially referring to patients, serves as a metaphor for le regard. Translated from the French as the gaze (as opposed to caring or esteeming), le regard indicates a mode of medical perception that enables the physician to look through the patient to recognize the disease. Under
the clinical regard, the patient becomes a background of objectivity (Foucault
1963, p. xiv). Through le regard, the doctor attempts to communicate directly
with the disease rather than with the patient, who is understood now in his or
her particularities only so that these may be abstracted and contextualized in
relation to the physicians medical reading (Foucault 1963, p. 8). Here lies the
premise 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 or
later, directly or indirectly, may be offered to the gaze (Foucault 1963, pp. 56).
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Simultaneously, le regard transforms everything but the disease, and its specific
signs and symptoms, into clinical ephemeranoisy distractions.To catch a fleeting glimpse of disease, then, the modern clinician must understand the individual only insofar as to abstract him or her and, thus, better distinguish true signs
of a disease from deceptive background noise: unrelated symptoms as well as
concerns, worries, and desires of patients and their families. Only serious medical discourse counts in the search for the disease. (See Dreyfus and Rabinows
[1983] discussion of Foucaults discursive interests.) House M.D. repeatedly
demonstrates 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 with
patients.
FOREMAN [to Cameron]: Isnt treating patients why we became doctors?
HOUSE: No, treating illnesses is why we become doctors.Treating patients is
what makes most doctors miserable.
FOREMAN: So youre trying to eliminate the humanity from the practice of
medicine?
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 the
human body. Foucault distinguishes the recognized (reconnaitre) from the
known (connaitre). The recognized refers to the disease discovered in the
body, the known the ideal concept sought through medical investigation. Both
the recognitive and cognitive acts help elucidate the emerging pathological
process, which unfolds concurrently within the patient and apart from the
patient. In other words, the patient is simultaneously important, as the medium
in which the disease is recognized, and irrelevant, as clinical ephemera. Foucault
explains:Paradoxically, in relation to that which he is suffering from, the patient
is only an external fact; the medical reading must take him into account only to
place him in parentheses (p. 8). By describing the patient parenthetically, Foucault references Edmund Husserls (1962) phenomenology of the early 20th century. Like le regard, phenomenology attempted to refine the scientific gaze and
bracket irrelevant or ephemeral beliefs and perceptions in order to understand
the thing in-itself. Similar to abstracting the patient, the physician also must separate himself, the observer, from what is observed, creating a gaze that is objective, meticulous, and possesses a passivity that dedicates it to the endless task of
absorbing experience in its entirety, and of mastering it (Foucault 1963, p. xiv).
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Thus, in House M.D., House is indifferent to what any of his patients have to
saywhether they are truthful or deceitfulbecause le regard has rendered patients narratives superfluous (see also Fissell 1991; Kleinman 1988). This is how
House can do his doctoring on a white board far removed from a patients bedside. Moreover, the only relevant discourse is the serious speech acts (see
Dreyfus and Rabinow 1983, p. xxiv) of the physician, who developed into a professionalized expert with increasing power and authority in the late 19th and
early 20th centuries. The patient, during this time, became silent. In fact, this is
how House prefers it: when describing a 29-year-old patient who has lost the
ability 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 clinical
ephemera, this silencing of the patient completes the medical revolution Foucault identifies in The Birth of the Clinic.The subtraction of the patient is crucial to modern medicine because the individual lives, experiences, and bodies of
patients and the individual biases of physicians may conceal the true forms of
disease even as patient signs and symptoms reveal them.Thus,
the doctors gaze is directed initially not towards that concrete body, that visible
whole, that positive plenitude that faces himthe patientbut towards intervals
in nature, lacunae, distances, in which there appear, like negatives, the signs that
differentiate one disease from another, the true from the false, the legitimate
from 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, which
dehumanizes his patients, staff, and supervisors, House subtracts the lying bodies that surround him in the clinic from his mathematical diagnosis of disease.
House uses the technique of le regard to avoid interacting with human subjectspatients, family members, hospital staff, administrators, lawyers, other doctors, and even himself. In the television show, this approach provides remarkable
results. Despite his petulance, House is respected for his detached diagnostic acumen.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 in
the show occurs in the differential diagnosis room, far removed from the bedsides of patients. Another portion is dedicated to conducting laboratory tests on
patients. Only a fraction of the program depicts any of the doctors talking with
patients.2 This distanced diagnosis, a cornerstone of the modern medicine Fou2 See,

for example, Paul Starrs (1982) discussion of how scientific medicine and its concomitant
detached technologies such as the microscope, X-rays, and chemical and bacteriological tests made
it possible to remove part of the diagnostic process from the presence of the patient into backstage
areas where several physicians might have simultaneous access to the evidence. . . . The collegial
exercise of authority strengthened the claim to objective judgment (p. 137).

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cault describes, is necessary because the gazing clinician, in order to identify and
treat the ideal disease, imposes meaning on what the patients individual signs
and symptoms signify collectively. The collection and interpretation of signs is
important for two reasons. First, the clinical disease may well share characteristics of other illnesses (fever, gastrointestinal distress, etc.). Second, the disease also
may vary in its degree (a severe case vs. a mild one), yet be manifested by the
same conditions. As House reminds his colleagues in season three,everything is
conditional. The modern medical gaze succeeds when it abstracts the real disease from its conditional manifestations.
House M.D. glorifies le regards dehumanizing medical approach when House
announces that Humanitys overrated, and when his colleague describes him as
having a disdain for human interaction (The Mistake, Episode 208). In this
way, le regard detaches the physician from the patient emotionally, linguistically,
and morally.The modern physician need not know a patient as an individual, but
merely as an object of rational, scientific inspection. When asked how he can
treat a patient without meeting him, House tells a patients father: It is easy if
you dont give a crap about him.Thats a good thing. If emotions made you act
rationally, well, they wouldnt be called emotions, right? Thats why we have this
nice 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 speculative
notion of general patient health.The absence or presence of a disease can be empirically verified, whereas general patient health (with its sociopolitical associations and underlying subjectivity) cannot be reduced to empirically validated
truth claims. Armed with an ethic independent of the patients general health,
the physician may commandeer the patients narrative, replacing it with a narrative that describes the physicians encounter with the disease. Historian Mary
Fissell (1991) suggests that the modern physician hijacks the patients narrative,
filtering the truly medical from the trivial and rephrasing medical stories
in inaccessible, Latinate, professionalized language. Because le regard subtracts the
patients own narrative history, privileging instead the clinical signs of disease, the
patient is transformed from a human, moral agent into an object of medical science. Foucault explains that during the transition from a premodern medical system to a modern one, the patient acquired the status of object and the clinical
experience became that opening up of the concrete individual, for the first time
in Western history, to the language of rationality (p. xiv).
Given this transformation, there is no reason the physician cannot experiment
on the patient, so long as the physician maintains a view toward accurately diagnosing and eliminating the disease. For le regard, experimentation on bodies
became as indispensable as it is for the natural sciences. The conditions that
united in the 19th and 20th centuries to transform medicine into a clinical science made it possible . . . for the patients bed to become a field of scientific
investigation and discourse and for the patient to be observed in the same way
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that we observe the stars or a laboratory experiment (Foucault 1963, p. xv).This

experimental approach to medicine is critiqued in House M.D. when hospital
administrator Lisa Cuddy reprimands House, saying that doctors dont prescribe
medicine 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 absolute
authority in the medical encounter and often mixed patient care and medical research (Rothman 1991).
Nearly every installment of House M.D. portrays House experimenting on
patients (for therapeutic, not scientific or financial, reasons). Experimental tests
facilitate physician-disease communication, as House explains:The more symptoms we can force out of [a patient], the more tests we can do. The more tests
we do the more information we get, the quicker we make a diagnosis
(Sleeping Dogs Lie, Episode 218). Consequently, House pretends to botch a
lumbar punctureto the painful chagrin of the patientto see if this initiates a
hypertensive crisis (Deception, Episode 209); ignores a patients DNR order
and intubates him when a treatment causes lung failure (DNR, Episode 109);
puts a patient into a medically induced coma so he may continue running diagnostic tests after the patient refuses to consent (Informed Consent, Episode
303); and orders his subordinates to place two similarly ill newborns on different drug regimens to reveal which disease is the culprit (and craftily uses medical 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 getting
a different treatment.
HOUSE: Sorry. Cant do that. It would be unethical for one patient to know
about 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 the
quest to diagnose and eliminate disease.This utilitarian approach is expressed by
House when he explains, I take risks. Sometimes patients die. But not taking
risks causes more patients to die (Detox, Episode 111).
House M.D., however, presents more than a depiction of the gazing doctor and
what 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 in

his diagnostic quest each week, the show also offers House up for scrutiny, an
object of the television viewers gaze. House may be a hero, but he is a tragic
hero. He walks with a cane, refuses to dress like a doctor, and is addicted to opiates, much like his literary equivalent, Sherlock Holmes. The opening scenes of
the pilot episode depict the tension, both visually and verbally, between Houses
outmoded form of clinical medicine and the contemporary managed care system: as Dr. House and Dr. Wilson walk the halls of the hospital, it is unclear to
the viewer who is the authority. Wilson, wearing slacks, a tie, and a white lab
coat, carries a patients medical record. House, sporting disheveled street clothes
and an unshaven face, clutches a cane. At best, House seems an aging man with
an uncertain future, at worst, similar to Karl Marxs (1867) workman languishing with the division of labor in capitalistic manufacturing, a crippled monstrosity (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 that
attitude?
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 lacks

social 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 physicians
were the arbiters in the medical encounter, holding sway over hospital management, medical education, regulations, drug companies, and patients. (See Starr
[1982] for a discussion of the consolidation of medical authority and the reconstitution of the hospital in America between 1850 and 1930; see Rothman
[1991] for a discussion of physician-directed ethics during the first half of the
20th century.) Physicians no longer enjoy such comprehensive authority, and
much of their power has been usurped by the patientrediscovered as an autonomous subject within medicine in the 1960s and 1970sas well as by the various third parties that have begun to crowd the exam room.

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Diagnose the Present: Postmodern Medicine

Gregory House is a symbol of everything wrong with the health care industry.Waste. Insubordination. 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 20thcentury wars. Images of the Somme, Guernica, and Auschwitz provide haunting
testimony of the consequences of high-tech warfare (see Keegan 1978).
Philosophers and artists thus reconsidered the combination of science and industrywhich marked the height of modernism and intended to improve the
human conditionas largely responsible for a science of inhumanity that included the development of battleships, tanks, machine guns, high altitude bombers, submarines, and biological, chemical, and nuclear weapons.This science also
gave rise to compulsory sterilization laws under the guise of eugenics, Nazi
experimentation conducted by physicians on concentration camp prisoners, and
various ethical issues in clinical research (see Beecher 1966). By mid-century, the
legacy of modern science looked bleak. Philosophical postmodernism reflected
a general suspicion toward a doctrine that seemed prepared to sacrifice the lives
of millions in the pursuit of objective truth in every aspect of human life: politics, art, and science (including medicine). Reacting against modernism, postmodernism continues to destabilize concepts such as presence, historical
progress, epistemic certainty, univocal meaning, and the role of central hierarchy
or organizing principles.3
The lure of modernism lay in its promise to produce a single truth of human
experience based on the objectivity of the scientific method. In contrast to Husserl, Martin Heideggers Being and Time (1927) demonstrated the impossibility of
such objectivity.Thus, Husserls phenomenological movement, which advocated
bracketing ephemera, gave way to a new hermeneutic that involved a profound
skepticism of the single, objective narrative of modernity. This postmodern
movement accused objective science of concealing racism, sexism, homophobia,
elitism, ageism, and ethnocentrism. To address this bias, postmodernism demanded political correctness, and to offset the authority of modernitys unilateral narrative, postmodernism required a proliferation of participants in narrative
history.
We define postmodern medicine as the reintroduction of the patient and
other stakeholders into the medical encounter that has occurred since the 1960s
and 1970s. This era has included the publishing of Henry K. Beechers Ethics
and Clinical Research (1966), the end of the 40-year Tuskegee Syphilis Study
in 1972, the adoption of a Patients Bill of Rights by the American Hospital
3 It

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

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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 allowed
the 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 equation, the patient recouped some of the medical decision-making authority (and
concomitant responsibility) the clinician had commandeered with le regard.
The expansion of the medical encounter, however, did not stop with the inclusion of patients and their families. Financial stakeholders, such as HMOs,
PPOs, and hospital administrators, make medical decisions based on the economics of health care. Pharmaceutical companies influence the prescriptions
written by physicians and demanded by patients. Concerns over medical justice
mean that the lawyers, judges, and juries who adjudicate malpractice cases
inform medical protocols and standards. Finally, moral concerns related to particular practices, procedures, and research are deliberated by legislators and voters. But the postmodern skepticism that followed World War II could not fully
supplant the role of the modern physician. Postmodernism may acknowledge the
significance of every human, but it must also recognize the knowledge and skill
of trained professionals. Consequently, medicine in the postmodern era includes
the modern doctor, generating an important tension in contemporary medical
encounters that is dramatized in House M.D.
While Dr. House himself personifies le regard, his colleagueshis boss, Dr. Lisa
Cuddy; his friend, Dr. James Wilson; and especially his three subordinates, Drs.
Allison Cameron (an American woman), Robert Chase (an Australian man), and
Eric Foreman (an African American man)act as postmodern foils.The primary
function of these supporting characters is to raise concerns about Houses distanced, authoritarian, scientific style. In the second season, for example, Cameron
struggles with telling a seemingly healthy university employee that she has
metastatic squamous cell lung cancer and about six months to live.While House
maintains that Cameron has done everything she needs to do except tell her
patient that shes dying, Cameron soft-sells this conclusion to her patient, whom
she continues to put through medical tests. When the patient wonders why all
the tests have been inconclusive, Cameron replies,Diagnostics is more of an art
than a science (Acceptance, Episode 201). But these comments signify more
than Camerons being too intimate with a patient. A fundamental element of
postmodernism is the repudiation of objectivity as desirable or possible. Postmodern medicine (even if primarily for legal reasons) openly acknowledges that
diagnosticsand really, all of medicineis more art than science, or at least
some combination thereof. Echoing this view, Cuddy admits that reading brain
MRIs is not an exact science (Role Model, Episode 117).
House M.D.s writers demonstrate how physicians today share decision making with postmodern stakeholders.While postmodernism grants patients authority, true decision making is often usurped by the new medical bureaucracy,
which has concerns of its own. These concerns are expressed when Edward
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Vogler becomes chair of the hospitals board of trustees:I want to run this place
like a business. . . .The product that youre selling is good health. It shouldnt be
a tough sell (Control, Episode 114).Vogler characterizes Houses exercise of
medical authority and independence as insubordinate and wasteful. The
accusation of insubordination reveals the postmodern hierarchy in medical
decision making to which the physician is now accountable. The accusation of
waste reveals the new medical ethic that places the financial health of the hospital above the health of patients. In the Vogler storyline that spans several episodes, Cuddy references the modern medical ethic and reminds Vogler that saving lives is what hospitals do (Babies and Bathwater, Episode 118), even while
she acknowledges the postmodern ethic and accepts many of Voglers recommendations. House, as the archetypal modernist, regrets this proliferation of
stakeholders, asking, Is the hospital getting out of the dull business of treating
patients? (Control, Episode 114).
While House may not agree, there are benefits of this postmodern ethic.The
importance of the artistic, humanistic approach to medicine is well documented
in medical literature. Numerous studies have shown that the White Coat Syndrome can adversely affect patients vitals, and things such as laughter, positive
attitude, and even prayer can improve medical outcomes (Bennett 2003; Bennett
et 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 medicine, the success of postmodern concern for the patient is regularly on display.
In a first season episode, for instance, Foreman leaves the hospital to investigate
a dying homeless womans case. He uncovers the mystery of her pastthat she
wrecked her car, causing the death of her husband and son, the guilt of which
leads to her psychological collapse and destitution.The episode ends with Foreman returning to the hospital to comfort her, pretending to be her dead husband, forgiving her for the accident, and watching her die with some recovered
peace of mind (Histories, Episode 110). Through this scene, House M.D. reminds the viewer that doctoring involves more than simply communicating with
disease. In this case, the disease has prevailed, and so Foreman communicates
with the patient.
House, in contrast, demonstrates his resistance to postmodernism by his politically incorrect behavior toward patients and colleagues. He shows no sensitivity
toward matters of gender, race, or class. He admits he hired Cameron because she
is attractive, Foreman because he has a criminal record, and Chase because his
father called in a favor. He regularly refers to Foreman as the dark one, comments on the breasts and buttocks of Cameron and Cuddy, and belittles Chases
bourgeois upbringing. But even House gets into the postmodern game on occasion. In the pilot, he visits a patient who has refused treatment in an effort to
change her mind.Tired of being experimented upon, the woman demands med230

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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 that
will communicate with the patient and address her needs, before administering
the 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 greater
decision-making authority in medical care.This elevated power of patients, however, often reveals the modern-postmodern tension within the physician-patient
relationship. Postmodern patients expect their health care providers to interact
with 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 to
consent to Houses treatment, because she believes her sons explanation of how
he became ill while House does not. In a dramatic critique of le regard, the mothers skepticism of Houses diagnosis turns out to be correct:
FOREMAN: Dr. House wanted your son to get the medicine he needed. He
was 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, thats
true 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. Diplomacy
becomes a factor in medical decision making, and bedside manner a key element
in establishing a patients trust.
This dimension is exacerbated when the patient possesses some or even significant 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 browbeat
them until they made the choice you knew was right.Youd shove it in their face
that its just a damn leg (Three Stories, Episode 121). House, however, insists
its my leg. Its my life.
As a patient, House expects to be a part of the medical narrative, something
he denies his own patients.After he is shot in season two, for example, House requests information about his surgery and the treatment that was administered to
cure his leg pain.They dont like to release patients operative notes, Cameron
tells 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 that
the pain now returning to his leg is not the failure of the medical treatment but,
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rather, the pangs of middle age (Meaning, Episode 301). House insists that
his knowledge of his own body surpasses that of any physician: How can you
be 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 repeated
to further illustrate the discord in medicine today. In TB or Not TB (Episode
204), House refuses to allow a renowned but ill doctor to be part of the diagnostic process, and when Foreman catches a disease from a patient in EuphoriaPart 1 (Episode 220), House similarly claims Foreman is not objective.
House orders Foreman to simply eat your meals, take your temperature every
half-hour and any meds I command you to take. Being a patient, from the modern doctors perspective, means being subtracted from the entire medical process
despite 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 is
often aware of modern medicines shortcomings and failings. Even a teenage
patients girlfriend in Occams Razor (Episode 103) is not placated or duped
by 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 be
treating 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 modernist
assertion in the above excerpt: the scientific cause-and-effect approach may not
be infallible in health care.Ailments often have more than one cause, which may
or may not be knowable, and treatments and cures, whether accessible or affordable, do not always exist.
On the other hand, postmodernism has produced its own predicament.While
it has attempted to revive the humanity in medical practice, the danger is that it
may have introduced too many stakeholders. With strangers crowding the postmodern exam room and vying for attention, control, and bottom-line profits
(Rothman 1991), health care practitioners have diminished authority and minimal interaction time, and often must treat patients more like automobile parts on
a Ford assembly line. House, for all of his modern rhetoric and postmodern inadequacies, is anything but an automatic motor of a fractional operation (Marx
1867, 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 2,500
years,Western philosophy and science have struggled to eliminate the obscuring
power of what Plato called doxa, Nietzsche called the herd, Heidegger called
the they, and Kierkegaard called the crowd: The noisy, voting crowd is untruth, because it ignores the individual for the sake of the crowd (Kierkegaard
1975, p. 94). House ignores the crowd for the sake of the individual.
The postmodern state of American biomedicine champions clinical ephemera, creating indecision and misplaced agency within the medical encounter. By
allowing greater participation in medical decision making, practitioners must
collaborate with patients and other third party stakeholders who may lack the
knowledge necessary to make an informed decision. Foreman offers a prime
example in Paternity (Episode 102), when he tries to obtain consent from the
parents of a teenage boy: Well, the antivirallook, Im sorry. I can explain this
as best as I can, but the notion that youre going to fully understand your sons
treatment and make an informed decision isis kind of insane. Heres what you
need to know. Its dangerous. It could kill him.You should do it. Bemoaning the
dilemma inherent in informed consent, Foreman explains: We expect family
members to make decisions about their loved ones after a 10-minute briefing
that were agonizing over even with years of medical experience (Euphoria
Part 2, Episode 221).
Relying instead upon le regard, House rarely agonizes. Approaching illnesses
scientifically, he bases his diagnoses on the best available evidence and his treatments on his diagnoses.This methodology leaves little cause for either agonizing
or 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 be
abstracted from the lies of the postmodern everybody. Painted as both hero and
antihero who acts the same no matter the situation, the character of Gregory
House enables House M.D. to explore whether a modern clinical physician
canor 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 generate an intimacy with the patients and their signs, symptoms, and diseases. The
viewer, like one of Houses staff, is invited to participate in the practice of le
regarda fellow investigator staring at Houses white board, trying to identify the
disease.The patients are objectified by the shows physicians, with the help of le
regard and biomedical technology such as X-rays, CAT scans, and MRIs. Patients
also are invaded by the camera as it moves through their bodies in search of the
disease.The viewers location, utterly separated from the patient and the clinical
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ephemera, reifies the modern notion that the objective viewing is knowing.
In this way, the viewer, sitting at home watching television, becomes the ultimate
House.
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 clinical
gaze.The camera follows Rebecca, a 29-year-old female soon to be Houses first
patient, as she travels to work. Clearly anxious, she is seen riding a crowded city
bus and then crossing an encapsulated pedestrian causeway to reach her destination, the school where she teaches.While discussing with colleagues and students
how she spent her weekend, Rebecca dramatically falls to the floor, convulsing
violently.The images and dialogue of this scene, like Houses mantra that everybody lies, have double meanings. Rebecca is infected with Taenia solium, a tapeworm found in pork. For the parasite to cause disease in a human body, it has to
enter that body and be transported to a susceptible site, similar to Rebeccas use
of mass transit. T. solium first enters through the mouth, then switches modes of
transportation in the digestive track, and finally rides the circulatory system to
the brain.A viewer practiced in le regard would be able to diagnose Rebecca from
these 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 with
a new paramour. In a premodern medical system, such promiscuity might be
deemed the cause of her disease; however, in the modern system that Foucault
describes, it is only the substantive taeniasis that is the culprit. As with all of
House M.D.s patients, Rebeccas pre-hospital life is abstracted at the top of the
show, and the viewers relationship with her, just like hers with House, ends once
the disease is diagnosed.
House M.D. is similar to other medical programs, all of which offer a look at
the medical world and at the public and private lives of medicines key players.
And although they are intended as entertainment, such shows can affect the
practice of medicine (Chory-Assad and Tamborini 2003). For example, researchers Michael Pfau, Lawrence J. Mullen, and Kirsten Garrow (1995) have examined how fictional medical programs influence public perceptions of physicians
by exploring what sociologist Erving Goffman has described as the front region 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 back
regions, revealing occasional uncertainties in diagnoses and mistakes in treatment,
and exposing unflattering personal traits (adultery, arrogance, and avarice, to
name a few). (p. 444)

Thus, Pfau and colleagues conclude, no longer are television physicians super
doctors in terms of their integrity, kindness, professionalism, or standing in the
community.This is hardly surprising, considering postmodernism candidly ques234

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tions such romanticized and one-sided depictions of anyone, particularly those

in positions of power.A quick review of recent medical shows provides evidence
of 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 perfect, as viewers witness how doctors personal and professional lives intermix.
However, House M.D. holds not just the medical realm up for inspection but
also medical philosophy. Houses personification of le regard remains untouched
by his personal and professional strengths and shortcomings. He regularly ignores
comments by patients and colleagues about his rough demeanor, his lack of
humility, and even his success in diagnosing disease.Whether House succeeds or
fails, the audience never doubts the efficacy of his method. Even when le regard
falters, as it often may, viewers never suspect the method itself of human frailty
or avarice. This is the power of an objective method. Although the viewer is
drawn into Houses personal life, as with any medical program, House M.D. perpetually reminds the viewer that Houses drug addiction, sexual deviance, and
inability to maintain healthy relationships with other adults are irrelevant to his
practice of medicine.At this level, House M.D. extols the virtue of methodology,
reminding us that the backstage personalities Pfau, Mullen, and Garrow have
uncovered in other medical shows reveal nothing but clinical ephemera, of no
consequence to the practice of objective medicine. Houses creator and producers have fashioned their title character in this way on purpose. As executive producer Paul Attanasio (2006) explains: What do doctors really think of their
patients? What does a doctor say when he leaves the room? And just make it such
that he says that while hes in the room. The collapsing of Houses front and
back 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 tension
within the medical encounter as well as dissatisfaction for physicians and patients
alike.Although medical schools continue to train physicians in le regard, physicians
are expected to behave according to a postmodern ethic that may place them at
odds with that regard (for example, recognizing patient autonomy, sharing authority with various third parties, and managing their practices using a business
model).This expectation is proving too complex.The inclusion of a broad spectrum of lay participants in health care works at cross-purposes with the scientific
goal of disease identification and elimination. This duality produces an ethical
contradiction in the American medical system. This contradiction may be responsible for other contradictions (symptoms), perhaps explaining how American
medicine offers the finest care in the world but struggles to provide basic health
care to a large and growing number of its citizens. Although Dr. Gregory House
plays the role of hero, House M.D. reminds us that this problem is severe, mortal
for some, and that a simple return to modern medicine an unlikely and perhaps undesirable solution. Still, in this new millennium nothing less than the
ethic of medicine is at stakewhether medicine remains fundamentally a natuspring 2008 volume 51, number 2

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ral science that treats disease or a human science that services a broader sociopolitical purpose.
In the meantime, shows such as House M.D. will continue to be a mirror la
Hamlet, 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 courses
of action. But, like Gregory House and his colleagues, we pursue the very thing
Foucault (1963) suggests we may never possess: the ideal configuration of the
disease [in which it] becomes a concrete, free form, totalized at last in a motionless, simultaneous picture, lacking both density and secrecy (p. 9).

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