Monthly Archives: August 2010

Nice is overrated

Mélanie Frappier on the necessity of conflict, as exemplified by House. M.D.

House and Socrates. Two cases, same symptoms. House’s best friends describe him as rude, arrogant, and offensive. He never misses a chance to sarcastically pick people apart. He refuses any administrative or clinic duty. His sharp mind has made him a leading expert in diagnostic medicine, yet he doesn’t write up his medical cases for journals; the “ducklings” – Foreman, Cameron, and Chase – do it for him.

The only person who sometimes manages to control House is Cuddy, the dean of medicine and hospital administrator. While she admits that he is the best doctor she has, House’s obsession with his cases is at times a costly nightmare. He hides when on compulsory clinic duty. His unorthodox, and sometimes outright unauthorised, treatments lead to billing problems and lawsuits. His refusal to endorse a new drug costs the hospital a $100 million donation. He destroys the hospital’s MRI machine, attempting to scan the bullet-riddled skull of a corpse (a scan Cuddy had, of course, forbidden).

House doesn’t show any more concern for people than for financial matters. He bursts in on other doctors when they’re with their patients, or calls them in the middle of the night to discuss his cases. Yet he doesn’t listen to their opinions but sarcastically rejects all their answers, taking a vicious pleasure in humiliating them in front of their peers and patients. An “equal opportunity offender”, House is aggressive and demeaning with his own patients.

Is House simply a “raving lunatic”, or is his obnoxious behaviour a symptom of a more serious condition? We could paraphrase House (in “The Socratic Method”) and answer: “Pick your specialist, you pick your symptoms. I’m a jerk. It’s my only symptom. I go see three doctors. The neurologist tells me it’s my pituitary gland, the endocrinologist says it’s an adrenal gland tumor, the intensivist…can’t be bothered, sends me to a witty philosopher, who tells me I push others because I think I’m Socrates.”

Socrates? If there was someone ancient Greeks thought was a pest, it was he. He was probably a stonemason by trade, but Socrates clearly preferred to spend his time discussing philosophy, nagging others with questions about truth, beauty, and justice. He didn’t write anything himself, yet the oracle at Delphi declared, “No one is wiser.” Bright young Athenians, like Plato and Xenophon, were Socrates’ “ducklings” and immortalized him as the main character of their dialogues.

Because Socrates neglected his work in favour of philosophy, he was poor. Unable to properly provide for his children, Socrates was pursued throughout the city by his sharp-tongued wife, Xanthippe. While Xanthippe is remembered as the only person to have ever won an argument against Socrates – much as Cuddy is the only one who can sometimes bend House’s will – her admonitions had only a moderate influence on her strong-headed husband.

Like House, Socrates showed little empathy when engaging people in philosophical debates. While, unlike House, Socrates valued friendship, people were quick to point out that discussions with him were as “pleasant” as a stingray’s electric discharge. Arguably such unpleasantness was justified, because Socrates believed himself to be on a godly mission to show people that they didn’t know anything. Part of this mission was to undo the work of the Sophists, who, according to Plato, taught the art of winning arguments for the sake of winning arguments rather than achieving the truth.

Why stun and confuse people with ironical questions, if afterwards you only insult them and reject their solution? The answer lies in the so-called Socratic method.

The Socratic method is based on the idea that knowledge is something that cannot be given. Rather, you have to discover it for yourself. So the only way to help someone else learn anything is by asking questions that will help that person reason his or her way to the truth. True Socratic professors do not lecture; instead they perform cross-examinations of their students to help them discover the weaknesses of their own positions. This Socratic method, House believes, is “the best way to teach anything apart from juggling chain saws.”

The Socratic method does not transmit a lot of information in a small amount of time. That’s not its goal. Rather, it aims to make students realize that they don’t know as much as they thought they did. This is at odds with our current educational system, which tries to build students’ self confidence by emphasizing their accomplishments rather than their errors. So perhaps we’re teaching students the wrong things. So-called facts are continuously disproved, and theories change. What students need is not to learn how the world is, but how to think despite the fact that we don’t always know how the world is.

Realizing that we don’t know much is only the first part of the Socratic method. This is perhaps where House and Socrates differ the most. While Socrates was trying to make his fellow citizens realize how limited their understanding of the world was, House is attempting to solve medical mysteries that are already puzzling everyone. But here again House follows Socrates’ advice, using the “second part” of the Socratic method, the “method of hypothesis”.

Socrates’ own “makeshift approach” is presented in Plato’s Phaedo, where Socrates explains to his student Cebes that we can’t start our discovery of the world by observing everything about it. The sheer quantity of information we’d have to take into account if we tried to observe every aspect of a phenomenon would be such that it would “blind our soul” just as the observation of a solar eclipse would blind our eyes. At the beginning of “Three Stories”, for example, House presents the case of a farmer with leg pain. Students propose to take a family history of the patient, run a CBC, do a D-dimer, get an MRI, and perhaps perform a PET scan. When House tells them that the patient would have died if he’d been treated this way, a student cries out: “We had no time to run any tests; there was nothing we could do!”

So what should one do? In the Phaedo, Socrates tells Cebes: “In every case I first lay down the theory which I judge to be soundest.” This sounds like House’s “differential diagnosis”: first look at the different possible causes for the symptoms, then investigate the one that seems the most plausible. Sharp leg pain like the one the farmer has can be caused by exercise, varicose veins, injuries, and animal bites. As the farmer says he was in a field when he suddenly felt the pain in his leg where a puncture wound is now found, a snakebite seems the most likely solution. Adopting this avenue of research as a “working hypothesis” enables House to focus on the wound and discover – through an unsuccessful series of treatments for snakebites – that the wound was actually a dog bite.

Given House and Socrates’ insistence on knowing that we don’t know, we might be tempted to conclude that the next step of the method of hypothesis is this: find further evidence in favor of our preferred diagnostic, while keeping in mind that we really don’t know anything and being ready to abandon the diagnostic as soon as new symptoms contradicting it appear. Yet in the Phaedo, Socrates tells Cebes that upon choosing a hypothesis, “whatever seems to agree with it – with regard either to causes or to anything else – I assume to be true, and whatever does not I assume not to be true.”

So next we should assume we’re right? Coming from someone who claimed he knew nothing, this seems quite arrogant – even House-like. But actually, the arrogance both Socrates and House display is central to the Socratic method. When an exasperated Foreman reproaches House for his lack of humility after having repeatedly screwed up the diagnosis of trumpet player John Henry Giles, House snarls: “And humility is an important quality. Especially if you’re wrong a lot.” When Foreman cries out: “You’ve been wrong every step of the way!” House replies with a scowl: “Of course, when you’re right, self-doubt doesn’t help anybody, does it?”

House is telling Foreman that doubt will just prevent you from doing anything that would help you find the truth. You must accept the risk of being wrong, if you’re ever to know you were right. If you’re ready to discard your best hypothesis at the first sign of trouble, you’ll never go anywhere with any of your opinions, because there will always be some unexplained elements, some “yes, but . . .” options that will prevent you from pushing your hypotheses further. Before discarding your best hypothesis in favor of another, you need to give it the best, most convincing defense possible, in the same way that an attorney should give a strong defense before the accused is convicted of a crime.

The Socratic method is thus a paradoxical one. On the one hand, to practice it you must admit that you do not know the truth. On the other hand, you must act as if you were sure you knew the truth. But what if you’re wrong? This is why once we have come up with a hypothesis, based on what we think we know, we need others to challenge us, to perform a cross-examination on us. We need them to question us to find out whether we’ve made any incorrect assumptions, used enough evidence to support our conclusion, or chosen our hypothesis based on unacceptable – yet perhaps unnoticed – personal prejudices. In the episode “The Socratic Method”, House and his team have been investigating the deep vein thrombosis of a schizophrenic woman named Lucy. Despite the opinion of a legion of specialists, House wonders if the woman really is schizophrenic. When he calls his team to the hospital in the middle of the night to discuss his worries, Foreman complains, “If any of us did this, you’d fire us.”

“Well, that’s funny,” replies House, “I thought I encouraged you to question.”

“You’re not questioning. You’re hoping. You want it to be Wilson’s. Boom. Give her a couple of drugs, she’s okay.”

House is aware he could be wrong. But how could he himself doubt any part of the solution he believes to be the correct one? He came to the conclusion that Lucy wasn’t crazy based on what he thought was the most plausible argument. Others must seek out the argument’s weaknesses for him.

The role of objector that House and Socrates ask others to assume is an extremely difficult one to play. We’re drilled into believing that our teachers, superiors, and leaders are right. In a way, we’re like Foreman, who, in the episode “The Jerk”, goes against his best judgment and follows House’s order to keep the patient on immunosuppressants after the latter tells him: “Look, you got two choices. Engage me in a futile argument and do what I asked or just do what I asked.” And so most of the time we just stop thinking: we either accept others’ positions – even if we disagree with them – or we’re “tolerant” and let them “believe what they want.” We almost always forget the third option (the one House hoped Foreman would choose): confront others on their beliefs.

Like Socrates and House, we need people to confront us. If others either agree with us or “agree to disagree with us” to avoid engaging us in debate, we’ll stay confined to our own little reality. We need someone to stand up against us.

Yet very few people will do this for us, because they know we’ll reciprocate and ask questions about their beliefs and opinions. Having one’s most basic assumptions challenged is unpleasant, unsettling, and considered offensive in our society. Most people will simply refuse to do it unless … well unless they are attacked and feel threatened. To learn anything, people like House and Socrates need others to question their opinions. Since others usually avoid conflict, they have no choice but to relentlessly attack people’s beliefs from all sides, and harass them with questions and ironical remarks, until someone “awakes from their slumber” and strikes back, criticizing House’s or Socrates’ own assumptions.

Should we condemn such an attitude? If we think about it, an education that wouldn’t challenge and change the ideas students already have would be a poor education indeed. And a doctor who wouldn’t display a healthy skepticism about the current state of medicine wouldn’t be more than a medical ATM, dispensing drugs according to some pre-established guidelines. Yes, just like physical fights, intellectual confrontations are painful. But they lead to our greatest discoveries. At least with respect to knowledge, House is right: “Being nice is overrated.”

Edited and abridged from House and Philosophy: Everybody Lies edited by Henry Jacoby, part of Blackwell’s Philosophy and Popular Culture series, edited by William Irwin.

Mélanie Frappier is assistant professor of humanities and social sciences at the University of King’s College, Halifax, Canada.