John Tierney, the New York Times’s resident conservative editorialist, often comes off as a decent person - never more so than today, in his profile of Richard Paey, a Florida man with multiple sclerosis and spinal damage from a car accident who is dependent on chronic high-dose opiates for pain control. If you’re at all aware, those last seven words should tell you the whole story: yep, Richard Paey is now doing a mandatory minimum 25-year stretch in federal prison as a drug dealer, for taking his own medication, courtesy of the DEA.

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I recently saw an episode of the TV show “House” - about a misanthropic internist at a teaching h0spital and his awe-stricken residents who engage in extended, heated debates over otherwise ordinary clinical diagnoses, but spend strangely little time dealing with the actual practical matters of patient care. (The premise of the show is that “Dr. House” - the show’s title refers to the doctor, not the hospital - is such a renowned diagnostician that he is allowed the privilege of not carrying a patient load, but simply hanging around the building inserting himself into whatever weird diagnostic mysteries turn up and pulling amazing clinical feats out of his ass . . . a privilege that apparently extends to his residents as well.) After viewing my first and only installment of the show, I was contemptuous of its lack of realism and its typical TV overdramatization - the doctor bursting into an OR in street clothes and spitting onto a surgical field in order to stop a (suspiciously-quickly-arranged) liver transplant that only he realizes is the result of a faulty diagnosis, or the entire team of residents racing out to a patient’s home to dig up his dead cat for an autopsy, conducted by Dr. House himself, that will confirm the patient’s illness (. . . dig up his dead cat?).

I also hated the show for the violence it did to medical ethics, and the wrong impressions it was likely to leave in the public mind. In the episode I saw, a doctor pleads with the hospital transplant coordinator to “see what she can do” to bump a patient up the transplant waiting list “because he’s too sick to wait another day” - with not a word about the fact that transplant waiting lists are specificially prioritized by patient need already or that no one would, or would be able to, arrange special priority. Dr. House, in the meantime, orders his resident to deliberately lie to the teenage patient’s father about the patient’s condition in order to get the father to authorize the treatment House thinks is appropriate - nobody in the show ever suggests that House could just tell the father that’s the treatment he thinks is appropriate. The entire group of residents is nonplussed by the suggestion that they should not just give the standard treatment for the most obvious diagnosis if it will interfere with treatment for a possible, but less likely, illness they have not yet ruled out. (”Differential diagnosis” is apparently not taught at their medical schools.) The doctor and the father later engage in a fistfight over what treatment to apply - nothing in the entire episode suggests that the patient’s proxy has independent decisionmaking authority, or even hints at “shared decisionmaking” or “informed consent”. (From what I understand, the “backstory” is that Dr. House is angry and irritable due to constant hip pain - for which he is morphine-addicted - resulting from a botched surgical procedure, which he had explicitly refused to authorize but which his wife authorized as his proxy when he became unconscious, with the justification that because he was unconscious she then had the authority to override his previously-expressed decision. Apparently even Dr. House doesn’t have patient autonomy, in Dr. House’s world.)

An article in today’s New York Times comments on the show as well, noting similar lapses in realism:

My wife, a general internist, finds the show absurdly “unrealistic.” “Doctors don’t do that,” she cries whenever a House physician blithely ignores the boundaries of medical subspecialties. (The same doctors, for example, might perform cardiac catheterization, gastrointestinal endoscopy, bone-marrow biopsy and liver ultrasound.)

(The article, by Sandeep Juahar, MD, laments the most unrealistic aspect of the show: “It portrays a world where doctors have time to solve problems” - whereas, in reality, house staff are so overworked that they simply don’t think about the intellectual puzzles of medicine anymore, but simply process patients through procedures. He blames this partly on legally-mandated reductions in shift length, which is a controversial claim, but he’s probably right about the general trend. At any rate, that’s not what concerns me about the show, though.)

I resent these kinds of shows because of the unrealistic expectations they create. In some cases, they raise public hopes too high - the widely-watched “ER” (a fascination among many ethicists) was criticized for the fact that patients in the show’s emergency department never died; the public came to expect that any emergency or trauma death was malpractice. (I have read recently that the cop shows have the same effect: prosecutors have complained that jurors, having watched forensic-investigation shows, now expect that every case requires the extensive lab work, DNA testing, blood analysis, and other techniques - some of them fictional - that these shows highlight, and that defendants cannot be convicted without evidence from tests and machines that in some cases do not even exist in real life.) Worse, though, is when they distort actual practice, and especially when they show misbehavior that, in real life, would be unlikely or impossible.

The public already fears that transplant waiting lists are manipulated (such beliefs were widespread after Mickey Mantle’s liver transplant). For shows like “House” to suggest that doctors in ordinary hospital practice openly attempt to get - and succeed in getting - special treatment for their patients is irresponsible. For a show that aired only weeks after Terri Schiavo’s death to suggest that patient proxies are not authoritative decisionmakers only adds fuel to a controversial misunderstanding that, as we saw too well, can have terrible consequences. To suggest that perfectly ordinary diagnostic reasoning is somehow controversial, or that the fact that a treatment team could entertain multiple working hypotheses about a diagnosis is somehow scandalous or the source of conflict, leads patients to imagine that being faced with a difficult diagnosis is by definition poor medical practice. Some dramatization is expected, but to suggest that doctors have to engage in physical confrontation, or bodily intervene to protect patients from hastily-scheduled abusive surgery, is a disservice.

I have the same reaction to medical scandal-mongering of the Robin Cook/David Rorvik type: claims that doctors are deliberately killing patients to harvest their organs, or have cloned a human being, presented as plausible “insider knowledge”, are similarly irresponsible. (I don’t have the same objections to clearly science-fictional works like Frank Herbert’s “White Plague”, or Micheal Crichton’s “Andromeda Strain”, where the technical material is somewhat plausible but there was no attempt to deceive the public.) Deliberately inflaming public passions - and misconceptions - about momentous issues is a tawdry way to make your fortune, and has serious consequences.

As has often been remarked, the “doctor shows” on TV have played a significant role in shaping the public understanding of the medical profession and medical practice (the “Dr. Kildare” meme is still powerful decades after that show went off the air). I don’t want to claim that these shows have to regard themselves as public-service entities - for one thing, the unreality of the shows can be a powerful communicative element (”M*A*S*H” was never regarded as a realistic medical show, but it riffed on our expectations regarding doctors and nurses to say important things about medicine and our society), and for another, I don’t want to open a second front for “Parents Television Council” crabs to gripe about. And I certainly don’t want to suggest that these shows should become cheerleaders for the professions they portray, like the old “FBI” series was for J. Edgar Hoover. But some sense of responsibility - especially in fiction shows that pretend to portray reality, as opposed to clearly dramatized shows - is in order. In reaping the public’s attention, and the advertising dollars it brings, it’s not enough to provide a sensation in return; some thought should be given to whether what you’re saying to the public is true, and whether the expectations you’re leaving them with are plausible. Fictional shows are not true in the strict sense, but they can be believable. Believable fiction that creates false beliefs, however, is as irresponsible as a lie. Some lies can hurt.