What Is a Utilitarian?

With his “end justifies the means” approach, House appears to be acting from utilitarian considerations. Utilitarianism, which was developed by Jeremy Bentham (1748-1822) and John Stuart Mill (1806-1873), holds that the outcome of an action, for all those who will be affected by it, determines whether that action is morally right or wrong. So a utilitarian would consider how a procedure House wants to perform would affect not only the patient and his or her family, but also how it would affect the doctors, the hospital, and future patients. Morally right actions are those that produce good consequences overall; morally wrong actions are those that produce bad consequences overall.

In many cases, this seems to be the way that House reasons about his actions—he justifies them by their good consequences. For example, in “Meaning,” House tries to justify giving a cortisol shot to a patient who has been unable to move or communicate for at least six months. House tells Cuddy that if his diagnosis is right, the cortisol shot will give the patient the ability to walk again, hug his child, and dance with his wife; if he is wrong, the shot will not harm the patient in any way. House is clearly trying to justify giving the patient the cortisol shot by its potentially overall good consequences.

Or consider House’s reasoning in “Let Sleeping Dogs Lie.” A woman, Hannah, is in need of an immediate liver transplant. Her lesbian lover, Max, is a match and a willing donor. The team discovers that prior to becoming ill, Hannah had planned to break up with Max. This presents the team with a dilemma. If they tell Max, she may no longer be willing to be a donor and Hannah will die; if they don’t tell Max, both women will live. House reasons that they should not tell because two women alive and in good health are better than only one—even at the cost of some psychological pain. Again, House justifies his actions by claiming that they create the best possible outcome.

Act vs. Rule Utilitarianism

But how should we judge the consequences? “Act utilitarians” hold that we should judge each individual action according to the consequences resulting from that specific action. This allows us to take into account the unique circumstances of each act. It also, however, requires a lot of time and effort. Just imagine trying to decide whether to buy locally grown pears or pears imported from a poor nation. The locally grown pears require less fuel to be consumed because they don’t have to travel as far. This is certainly a great benefit to everyone currently on the planet as well as to future generations. However, the farmers of the poor nation may be relying on foreign consumers to buy their products. It might be the only thing keeping them from abject poverty. You would be stopped in your tracks in the middle of the grocery store trying to sort it all out. An act utilitarian would have to consider each individual purchase by itself. She would need to research each type of fruit at each market—where it came from, the plight of those who produced it, and so on—to decide which purchase would produce the best consequences.

This is why some utilitarians, called “rule utilitarians,” hold that we should act according to rules or principles that, in general, bring about the best consequences. In the scenario just described, a rule utilitarian would have to base her decision only on whether, in general, reducing carbon emissions or helping those who are impoverished produces the best overall consequences. Once she has made this determination, she can apply her rule to all of her future fruit purchases. This still requires some work, but not nearly as much work as act utilitarianism.

The philosopher Immanuel Kant (1724-1804) had a moral theory similar to rule utilitarianism. Kant (and his followers, called Kantians) also believed we should follow rules, but Kant was not concerned about the consequences of actions. Rather, Kant thought that it is the act itself that is either right or wrong, regardless of the consequences of that act. For instance, Kant maintained that lying is always wrong, even when lying is the only way to save a person’s life. He also held that it is never right to treat a person only as a means to an end. For example, it is okay to go to the doctor and make use of his expertise, but it is not okay to treat the doctor as a mere tool, as less than a person.

House favors considering particular circumstances and so tends to reason like an act utilitarian rather than like a rule utilitarian. Consider the episode “Babies and Bathwater.” In order to save an expectant mother and her unborn child, House must perform an early C-section. This will allow the mother to start a clinical trial for a promising treatment for her small-cell lung cancer, her best hope for long-term survival. Unfortunately, the trial starts well before her due date and the treatment would injure or kill the fetus. On the other hand, an early C-section would lower the baby’s chance of survival from nearly 100 percent to 80 percent. House, in his characteristically bad-tempered but honest manner, convinces the patient to have the C-section and start the trial. Meanwhile, he knows that she shouldn’t be admitted to the trial since there is a policy that no patient can be admitted to a clinical trial within a month of having a major surgery. The policy is meant not only to protect the patient, but also to protect the integrity of the trial’s results. Nonetheless, House gets her into the clinical trial by omitting her current condition and schedules the C-section. (The hospital administration gets wind of his plan before the C-section can be performed and it is canceled at the last minute).

House is clearly considering the unique circumstances of this particular case, reasoning that one participant who is not in compliance with all of the standards will not invalidate the results of the entire study or render them useless. The treatment will pass or fail the trial regardless of how any one patient responds. Furthermore, he is certain that the patient’s recent C-section won’t cause her any problems. House isn’t following a general policy, which, if followed by everyone, would provide the best possible outcome for all the participants and potential recipients of the treatment. Imagine that every physician decided that his or her patient’s noncompliance would not alone invalidate the results of the study. If a significant number of patients are admitted by physicians reasoning in this manner, then this overall noncompliance will cause problems for the trial. In fact, this is exactly what the policy is intended to prevent.

A rule utilitarian would follow the policy of not allowing any exceptions because this is the policy that leads to the best consequences when everyone follows it. This is also what a Kantian would do, because the alternative involves deceiving the experimenters. When we deceive someone, we are treating that person as merely a means to our own ends, which, as we have already seen, Kantians find unacceptable.

A similar situation arises in “Control.” A young female patient is in need of a heart transplant in the immediate future. Normally she would be placed at the top of the list, but House discovers that she suffers from bulimia. Furthermore, her bulimia caused the conditions that have made a new heart necessary. If her disorder is revealed, she will be placed so far down the list that she will almost surely die before receiving a heart—if she is even put on the list at all. After a typically frank conversation with her, House is convinced that she does not want to die and will mend her ways. In light of this he conceals her disorder from the transplant committee (as well as his team). She is placed at the top of the list, receives a new heart, and makes a full recovery.

House clearly brings about the best possible consequences for the patient. She has a new lease on life and is thriving. No one finds out about her disorder until it is too late to remove her from the list. Even then it is not clear, or provable at any rate, that House had prior knowledge of the bulimia. All this means that it is unlikely that the transplant system will suffer any harm. Physicians and patients will not lose faith in the system, and other doctors will not be inspired to follow House’s deceitful example. Indeed, House hides the patient’s bulimia from his team partly for this reason. But he also hides it from them for a more pragmatic reason: to prevent them from alerting the hospital administration and the transplant committee. After all, not every member of his team reasons like a utilitarian (especially Cameron). In this case, House’s reasoning is based entirely on bringing about a certain result, with no concern about treating people as more than a means to an end. Clearly, House is not a Kantian but rather an act utilitarian. His reasoning is based entirely on the particulars of this patient’s case.

Best Possible Consequences

Despite his utilitarian reasoning, it is not clear that House actually brings about the best consequences in all cases. Recall the episode “Acceptance,” in which an inmate on death row is saved from the poisons in the copier fluid he ingested. During his stay in the hospital it is discovered that he has a tumor situated above his pituitary gland, which may help to explain his sudden rages. Unfortunately, it is unlikely to overturn his conviction, and he is sent back to prison to await his execution. And recall the episode “Lines in the Sand” in which an autistic boy is saved from a nearly fatal parasitic infection only to return to his former, autistic self, leaving his parents to continue to monitor his every move.

Clearly, House is not able to bring about the best conceivable consequences in either case. The best conceivable consequence doesn’t have to be practically possible; it just has to be something we can imagine could (perhaps miraculously) be brought about. The best conceivable consequences in “Acceptance” and “Lines in the Sand” would be to change the inmate’s sentence and cure the boy of autism. However, it is not practically possible for House to bring about either of these consequences. The question then becomes whether he brings about the best possible consequences.

In the case of the inmate, we must consider whether an extended life (even if it is while incarcerated) is a better consequence than an immediate death. One might think that if the inmate lives, he will have a chance to appeal his sentence and receive a stay of execution. But, as Foreman points out, this is not very likely to happen. One might also reason that it is better because it allows for a better death. If they had refused to treat him, he would have died a painful death. Furthermore, because the tumor wouldn’t have been discovered, he would never have had any insight into his own behavior. Of course, this better death does come at the cost of the psychological pain he will endure in the days leading up to his execution. In the end, it may not be clear whether the best possible outcome for the inmate was achieved. Remember, though, that the inmate isn’t the only person we have to consider. Preventing his suicide is probably the best possible outcome for those in charge of the prison. It might also be the best for those personally affected by his crimes. They gain insight, just as he does, when the tumor is discovered. It might help to answer some of their questions (such as “How could this happen?”) and give them a greater sense of closure and healing.

House thinks that the best possible outcome was achieved. He puts great value on life, at least life in which the person is conscious, aware of surroundings, and so on. Even if you have to live with tremendous pain, he reasons, it is better to be alive. House himself is in constant, unrelenting pain and shows no signs of ever considering suicide. We see his attitude toward life many times throughout the show in his actions toward patients as well. For example, House is vehemently opposed to euthanasia when there is a chance of treatment or a cure. Consider the episode “Informed Consent,” in which an aging scientist wants House to help him die. Everyone agrees that the man is in pain and everyone (except House) agrees that he is near death. Only when House determines that the man actually cannot be helped and his (painful) death is imminent does he agree to help him end his life. In order to make this determination, House has to trick the man and run tests against his (explicit) wishes. Others, including Cameron and Chase, don’t have the same view of life. They think that it is sometimes reasonable to prefer death over constant, unrelenting pain.

In the case of the autistic boy in “Lines in the Sand,” it is clearer that we also need to consider the outcome for those other than the patient. It is practically impossible to know what it is like to have his form of autism. Nonetheless, it is reasonable to suppose that even a life like this is preferable to death. The real difficulty arises in assessing what is better for his parents. If he were to die, this would certainly cause his parents a great deal of pain. On the other hand, it would also allow them to move on with their lives. If he were to survive (as he does), it would mean that they must either continue to give up their lives and care for his every need or put him in an institution. Caring for him is complicated by the fact that he has no emotional attachment to anyone. His parents are not getting any sort of love or even attachment in return for their efforts. This takes a great toll on them. But while putting him in an institution would take the pressure off them, it would also cause them a great deal of emotional anguish.

House seems to think that it would have been better for everyone involved if the boy had died. He thinks that the pain the parents are going through outweighs whatever pleasure the boy gets from being alive. And, it should be mentioned, House doesn’t believe the boy has much of a mental life, that he may not in fact take pleasure in being alive. This fits well his general views about life. Consider the way he reasons in “Fetal Position.” House doesn’t think that the unborn fetus’s life (he refuses to call it a baby) should be taken into account when deciding what should be done. He doesn’t think its life is valuable, just as he doesn’t think the autistic boy’s life is valuable. This is not to say that he would support actively killing the boy. It is just to say that he thinks the best possible outcome was not achieved. Wilson, characteristically, takes the other side. He reasons that the boy’s death would take a greater emotional toll on the parents than his life is currently taking.

In these particular cases, and probably others as well, House (perhaps) doesn’t bring about the best possible consequences. Still, he does bring about the best possible consequences in the majority of cases. As Cuddy says to a skeptical Tritter in season three, “He saves a lot more lives than he loses.”

Is House a Morally Good Person?

But is House really interested in bringing about the best possible outcome for everyone involved? Maybe not. The main reason House appeals to the beneficial consequences of a given action is that he knows it will satisfy the person who is asking him to justify the action. House will try to quickly and efficiently knock down any roadblock that is put in his path. If Cuddy were to become focused on the bottom line, House would justify his actions by demonstrating how those actions would save money in the long run. If Wilson were to become focused on advancing medical knowledge, House would justify his actions by showing how those actions would yield new information. It seems that what House is really interested in is solving the puzzle (arriving at a correct diagnosis). It’s only incidental that solving this puzzle is almost always beneficial to the patient.

Utilitarians hold that a morally good person is one who tends to bring about the best possible overall consequences. Even if House sometimes misses the mark and even if he acts for selfish reasons, his actions tend to bring about the best possible outcome. Making a mistake or two does not prevent someone from being a morally good person. Even the best among us, Mother Teresa and Gandhi for example, once in a while did something morally wrong. But not acting for the right reasons, with the right intentions, a majority of the time does seem like it might disqualify someone from being a morally good person. Many utilitarians also hold that a good person must not only do the right thing, but do it for the right reasons, with the right intentions.

At first it may seem that House is interested only in helping the patient insofar as it is a way to solve the puzzle. This is clearly not the right reason to want to help the patient, even if helping the patient is the right thing to do. But consider the episode “One Day, One Room.” In this episode a rape victim comes to the clinic and is seen by House. There is no puzzle for him to solve. If House was interested only in solving puzzles, he would have refused to talk to her and moved on to the next case. He does initially try to hand the case to someone else, but only because he thinks that he is unqualified to talk to her, not because he isn’t interested in talking to her. The patient refuses to talk to anyone else, and after she takes a handful of pills in order to get to see House, he agrees to talk to her. Not only does he talk to her, he actually tries to help her. He has been told that she needs to talk about what happened, and he keeps pushing her to do so. When she tries to direct the conversation away from her rape, he is at a loss for what to do. When he is uncertain how to answer one of her questions, he temporarily puts her under so that he can ask everyone for advice. Time and again, instead of walking away, he tries to help. Eventually she does talk about the rape. Everyone else is quite happy that she is talking about what happened to her; but House is upset that in order to help her, he had to make her cry and relive the rape.

Admittedly, this is only one example of House trying to help a patient without also trying to solve a puzzle. But it is enough to give us pause. Perhaps we should not rush to the judgment that House is a morally bad person. Perhaps he does act for the right reasons, despite all (superficial) appearances to the contrary. Only House really knows.