Dibala: Inject my IV with an air bubble. I will have another heart attack. No one will know... You tell my colonel I'm a sick dying old man who can't be trusted... You were trying to put a gun in his hand and point it at my head. The gun is now in your hand, that is a practical difference, not a moral one. If you want me dead, then pull the trigger. It is not so easy when you have to do it yourself.

Cameron: I guess I didn't want you dead.

―The Tyrant

The Tyrant is a sixth season episode of House which first aired on October 5th, 2009. When a controversial African politician (guest star James Earl Jones) falls ill, he is brought to Princeton Plainsboro for treatment. The team struggles with whether to help a merciless dictator being sued in the United States for crimes against humanity in his country. Meanwhile, Wilson tries to make peace with a feuding neighbor, but House 's prying exacerbates the problem.

The episode uses several characters to examine the dynamics of unequal power relationships. We start with Dibala, a political dictator who holds minority group within his country under his thumb in order to hold onto power with the majority. We then turn to Murphy, Wilson's downstairs neighbor who is also on the board of the building he lives in, who leverages sympathy, anger and authority to make life difficult for those who cross him. Next, we have Foreman who, a week into his new job, has fired his girlfriend and alienated his other employees. Although he now has the authority he has always wanted, he wonders whether his ability to wield authority is affecting his medical judgment.

On the sidelines we have House, who despite his setback insists on remaining the prima donna, leveraging his genius to work his way back into diagnostics. Once there, instead of being the humble man we saw in the last episode, we once again see him enjoying the torment he brings to his old team.

After an African dictator is served with a human rights lawsuit, he immediately starts vomiting blood.

Dibala is transferred to Princeton-Plainsboro Teaching Hospital to be treated by Eric Foreman. However, with Thirteen having been fired and Taub having resigned, he convinces Lisa Cuddy to assign Robert Chase and Allison Cameron to his team until he can find replacements. Cameron objects to having to treat Dibala, but Cuddy notes that he is a guest of the American government and the United Nations and they have been told to extend every courtesy.

Foreman is trying to explain to Chase why he had to fire Thirteen. They discuss the possibility of hemorrhagic ulcers in the lungs. The old team returns to Foreman's office to find House waiting for them. However, he is still waiting for his license to be reinstated. Dibala thought it was poisoning, but an environmental scan was negative. They also rule out acid reflux. Foreman thinks it is malaria. House accuses them of rushing to a diagnosis so they don't have to deal with him. House thinks it is dioxin poisoning, because it fits the symptoms. Foreman orders treatment for it.

Dibala wants to know if they are sure it is dioxin, but they admit they are not sure. Dibala talks to Chase about his Australian background and British education.

Foreman and House talk to Cuddy about House returning. Foreman objects, but Cuddy tells him to let House in on differentials, but House can't do procedures or have any contact with the patient.

Foreman goes to Thirteen about firing her to tell her House is coming back and she can have her job back if she wants it. However, she doesn't want it any more because she thinks Foreman wants to break up with her.

Chase goes to do clinic duty, but the "patient" begs him not to treat Dibala. Chase says he can't discuss the case, but the visitor presses on, telling him about the genocide. Chase apologizes and leaves.

House goes home to speak to Wilson. He wants to know why Wilson isn't using garlic or wearing shoes. He realizes he's doing it not to bug his downstairs neighbor. House wants to deal with him, but Wilson tells him not to because he's on the condo board. Cameron calls House to let him know Dibala is having a heart attack.

House comes back with a diagnosis of Lassa fever, however, it isn't endemic to his part of Africa. Dioxin poisoning has also been ruled out. However, House argues that Dibala's visit to Egypt would put him in contact with people who did have it. Foreman agrees to treat him for it.

Although Dibala's aide is angry, Dibala is more patient. He sees Thirteen outside the room and figures out she's Foreman's girlfriend. She tells Foreman she has a job interview and she realized he set it up. She agrees to go to dinner with him.

House meets the neighbor in the lobby of Wilson's building. The neighbor has a hook where his right hand would be. He complains about the noise House's cane. House starts off as a wise guy, but soon becomes conciliatory. However, the neighbor still threatens him.

Dibala has found someone who has had Lassa fever and wants them to take her blood to make serum for treatment. Cameron refuses, but the woman insists on the procedure. However, it's obvious she's being coerced. Cuddy orders Cameron to do it – the woman's family is probably being threatened.

Chase sees the man from the clinic walking through the hospital dressed as an orderly and calls out. He hears shots, but finds that Dibala's security team has subdued him, although some of the equipment is damaged. However, he notices Dibala's right eye is bloody despite the fact the assassin didn't injure him.

Chase treats the assassin who then admits he lied in the clinic; however, instead of his wife being a victim of the death squad, he was part of a death squad and can no longer live with himself.

The bloody eye was from an enlarged lymph node. House isn't participating in the diagnosis, but makes noises or faces and prompts Chase in pantomime whenever they suggest anything. Foreman still doesn't think it's infection, but asks House to talk. Foreman thinks it is lymphoma. However, Dibala's LDH is normal, but Foreman puts that down to Dibala's excellent liver function. Foreman orders a lymph node biopsy. When House leaves, he asks Foreman to close the blinds. When he does the words "Lymphoma – TADA!!" appear.

Wilson is talking to House about talking to the neighbor. House tells Wilson that the neighbor wasn't in Vietnam – he's too young and he has private medical insurance. He figures that they can blackmail him. Wilson tells him to apologize in writing and leave it at his door. He tells him it's hard to be nice to people you hate.

Dibala thanks Chase for saving his life. Chase asks if he was really preparing a massacre. Dibala tells him about what the rebels have done. He tells Chase he is estranged from his youngest son, who now attends Princeton University. He accuses the men he hired to run his Youth Labor League of causing all the abuse without his authority or knowledge.

House goes to drop off the letter, but the maid opens the door just as he's about to. Instead of going in, he drops the letter, then slips on the floor, spilling the pail the maid was using. He goes inside to mop up and drops off the letter inside. He sees a Canadian flag on the wall – more proof the neighbor wasn't in Vietnam.

Chase and Cameron argue about whether Chase should have stopped the assassin. Cameron says she's fine with the patient dying. She rules out lymphoma.

House confronts the neighbor. The neighbour accuses House of breaking in and threatens to send him to jail. House tells him that faking a medal is a crime too. The neighbor tells him he was in Vietnam with the Canadian Armed Forces for a peacekeeping mission and was crippled when he tried to save a young boy. He now suffers permanent pain as a result of his injury. House apologizes and leaves.

They inform Dibala that the biopsy was negative for lymphoma, but they realize he's suffering from short term memory loss.

Foreman takes Thirteen to dinner and tells them that Chase and Cameron are enjoying themselves. Thirteen tells him that instead of firing her he could have stepped aside, or let Chase or Cameron be in charge. Thirteen says she's having trouble understanding Foreman, and he says he thinks he made the right decision firing her. She leaves.

Cameron agrees with Dibala's military aide that Dibala is not mentally competent, and this may be the start of a downward decline. He also starts spiking a fever.

House thinks it might be scleroderma. However, Dibala has a fever and nodules on his fingers. Foreman thinks it is an infection. Foreman orders treatment for blastomycosis.

Cameron goes to treat Dibala and she realizes that he realized she told the military aide he couldn't be trusted. He has lost trust in her and thinks she is trying to kill him and tells her to go ahead and do it. She injects the intravenous line, but it's just medication. Chase tells Dibala not to touch Cameron again. Dibala tells him she's too weak to act on her own beliefs. He accuses his aides of the same weakness. Chase asks about the genocide. He says he will do whatever it takes to protect his country.

Wilson finds out House entered the neighbor's apartment. Wilson has to kick House out in order to placate the neighbor and keep him from pressing charges.

Cameron wants to do the blood test to confirm scleroderma. Chase agrees to get the sample. The test is positive, but they can't convince Foreman to change the treatment. Cameron asks if Foreman has told Thirteen he was wrong to fire her. When Foreman says he hasn't, she reminds him that he often retrenches instead of admitting when he's wrong. He agrees to switch to steroids.

House manages to sedate, tie up and gag the neighbor with duct tape. He tells him that he knows about his phantom pain and painkillers. He gets the neighbor to put his hand in a box. It has a mirror that makes it look like he has both hands. He tells him to clench both fists and let go. The pain disappears and the neighbor breaks down and thanks House.

Dibala's oxygen saturation drops. They find a bleed in his lungs and cauterize it. However, he has a dozen other bleeds into his lungs. They try to defibrillate him, but they can't get his heart started again.

Foreman is in his office despondent and House tries to console him. He's still not sure if the patient died because he switched the meds or didn't give him steroids in time. However, they can't do their own autopsy because the body is going back to his home country. House suggests they break into the morgue. Foreman attempts to break in but he finds an armed guard. Foreman finds out from the log book that Chase was in the morgue before the test and Foreman asks him why. He thinks Chase took blood from a dead scleroderma patient. Chase admits it and says he couldn't bear having him live because if they treat him he will return to his country to continue the genocide. If they tell the truth, Dibala becomes a martyr and genocides will be done for a long time in Dibala's name and honor. Foreman tells him he can't cover for Chase. Chase only asks that Foreman warn him so he can say goodbye to Cameron.

House returns to Wilson's apartment. Wilson notes the neighbor now sounds happy and has approved Wilson's garden expansion. He won't press charges, and doesn't want House to move out. He asks House what he did. House agrees to tell him, but Wilson doesn't want to know.

In the end, Dibala's son comes to see his deceased father all the while tearfully mourning his loss, Chase, plagued with guilt, goes to bed with Cameron while Foreman burns the morgue sign-in log to rid any evidence of Chase's involvement in Dibala's death.

Neither of the conditions which were part of the final differential is particularly rare, although both are difficult to diagnose as their symptoms mimic many common conditions.

• House tells Foreman he shouldn't be upset because he broke up with Thirteen because "It's not like she's the hottest woman in the world". This is a reference to the fact that Olivia Wilde had just been chosen by Maxim Magazine as the world's hottest woman.
• Early in the episode, Chase mentions that Dibala thinks it was an asssassination attempt, using "polonium, like that guy in London". This is an obvious reference to the case of Alexander Litvinenko, who was poisoned using polonium-210, ostensibly by the Russian Federal Security Service.
• When Ruwe is trying to persuade Chase not to treat Dibala, he mentions the 1994 Rwandan Genocide, wherein between 500, 000 and 1, 000, 000 ethnic Tutsi were killed by members of the Hutu majority. Ruwe references the fact that the UN for the most part did not intervene, as many members of the UN Security Council, especially the US, feared a repeat of the events in Somalia in 1993, culminating in the Battle of Mogadishu.
• When House pries Wilson as to why he stopped using garlic and wearing shoes, Wilson jokingly replies "I'm Vampire, Sookie, " a reference to the episode "Burning House of Love" in the HBO series True Blood where it is spoken by the character Bill Compton. Robert Sean Leonard also played a vampire in the 1987 film "My Best Friend is a Vampire".
• Sharm El Sheikh is a popular Egyptian resort town on the Red Sea, at the tip of the Sinai Peninsula.
• The reference to "holding up a boom box" is a reference to the ending of the romantic comedy Say Anything..., made in 1989.
• Mi Krop is a Thai dish consisting of fried rice noodles covered in a sweet sauce, often flavoured with lemon or lime.
• The Maple Leafs are a reference to the Toronto Maple Leafs, an ice hockey team in the National Hockey League. In French versions of the episode, "Go Maple Leafs" is replaced by "Vive le Quebec Libre" or "Long Live Free Quebec", a line from a controversial speech by French President Charles de Gaulle on his visit to Expo '67 in Montreal.
• Dibala's aide says that Dibala is protected near the UN until "[they] cross 42nd Street"; however, he is cut off by Dibala before he can finish. The UN is located on 42nd Street at First Avenue. The aide's implication is that Dibala somehow loses his diplomatic immunity away from the UN building, but this has no basis in fact (though he could be referring to Dibala's physical safety and UN-based security). As a high-ranking delegate to an international organization, Dibala has nationwide protection from prosecution, criminal or civil, so he is right to say that Dibala can ignore the civil suit.
• The downstairs neighbor presumably served as part of the International Commission of Control and Supervision.
• The way House waits for his neighbor, plunges a syringe in his neck to anesthetize him, fastens him to his chair with duct tape while he is passed out and sitting right in front of him when he wakes up, is most likely a subtle visual reference to the Showtime series Dexter, where the main character, Dexter, works in a very similar fashion in order to catch serial killers able to escape from the law. This way, Dexter can kill them himself with minimal risk.
• The fact that James Earl Jones is the guest star of this episode and that Wilson's neighbor is missing his right hand is a subtle reference to Darth Vader, who is voiced by Jones, cutting off Luke's right hand in The Empire Strikes Back.
• "It smells like... victory" is a quote from Apocalypse Now.
• "We're home in time for Ellen" is a reference to The Ellen DeGeneres Show.
• Chicken Florentine is a casserole chicken dish where the chicken is cooked, then baked in a white sauce flavored with Parmesan cheese.
• Cameron refers to the Death Row patient they previously treated as still being in prison. At the time of that case, New Jersey still had an existing death penalty statute for murder; it was subsequently abolished near the end of 2007, with all Death Row inmates having their sentences commuted to life in prison without parole.
• Interestingly, it is never revealed what African nation Dibala is the president of, though it's possible that this was done to not draw the ire of the actual leader of a country. There also exists no real-world African ethnic group called the Sitibi people. It's likely that they didn't reference any particular group as to not be insensitive.

• U.S. Code section 1350 deals with the failure of corporate officers to certify financial records. It's section 1091 that deals with genocide.
• The sign in sheet at the morgue is creased and folded when Foreman is holding it in the locker rooms. However, when Foreman goes to burn it later in the office, it's in pristine condition.
• Attempting to defibrillate someone with severe bleeding is pointless. Unless you can stop the bleeding, starting the heart again is only going to make the bleeding worse. Also, as has been pointed out numerous times, you never defibrillate a patient who has no heart activity. Defibrillation is for someone in ventricular fibrillation to restore the heart to a normal rhythm. If the heart has stopped, you have to treat the cause before trying to restart it.
• It's really a bad idea to use drugs that thin the blood (i.e. make it less likely to clot) if the patient has a recent history of severe bleeding.
• Heparin should never be used together with streptokinase, although other blood thinners may be mixed.
• Amphoteracin should never be "pushed" or injected directly into a vein. It should be allowed to enter normally with other IV fluids. Pushing amphoteracin is associated with low blood pressure, low calcium levels, arrhythmia and shock.
• One thing a malaria patient won't have is a mosquito bite. It takes at least seven days for malaria to incubate, more than enough time for the bite to heal.
• Chloracne is usually widespread, not just a single bump in a single location.
• Although anticentromere antibodies are suggestive of scleroderma, the more aggressive the form of scleroderma, the less likely a patient is to have high ACA levels. As such, the test should only have been mildly suggestive.
• Dibala's accent noticeably changes as the episode progresses, starting "African" before becoming close to Jones' natural US Midwest accent.

Refusal to provide care to a patient:

Since it's pretty clear that faking test results in order to create a situation where they receive the wrong treatment is ethically, professionally, legally, and criminally wrong, let's focus on where we all started - the decision to provide care to Dibala.

Although it's clear that a mentally competent patient may always refuse a particular treatment, the circumstances where a physician is allowed to decline a case are less clear. There are some circumstances where a physician in the United States is clearly permitted to decline to take on a patient, such as when the patient has no ability to pay. However, it's less clear when a physician may refuse to take on a patient for reasons of personal conscience.

Cuddy is probably the most at fault here. Although PPTH would have had a duty to treat Dibala as an emergency patient, once his condition was stabilized that obligation ended. It appears she was under external pressure to get her best doctor to take the case. Moreover, technically, as the attending physician, this is completely Foreman's call. Once he takes it on, his staff takes on the case as well. Cameron can object to providing direct treatment, but this is technically an issue she has to work out with Foreman, through the hospital if need be.

There are many other situations where hospitals deal with similar issues (such as staff working with contagious diseases) by asking for volunteers to work on the case. That most likely would have been the appropriate approach here.

Chase, who believes his obligations as a physician override his personal objections to the patient, is at least on solid ethical grounds.

However, this refusal to provide care only goes so far. For example, a physician who refused to treat Jewish patients on principle would most likely be in breach of professional obligations as well as human rights legislation. In addition, there is no issue with a physician not taking on a patient they are not trained to treat, such as an internist taking on a patient needing surgery. However, it's less clear cut if an otherwise properly trained physician refuses to provide particular procedures. For example, it's likely a trained obstetrics surgeon may still refuse to provide abortions. However, it's less clear cut if a family physician refused to prescribe contraception.

In any event, it appears clear that if a physician finds another physician who is willing to take on the patient, they can overcome any ethical difficulties that may arise from their own refusal. For example, if there are two doctors in a walk-in clinic and only one opposes contraception, allowing only the other doctor to see patients needing contraception is an acceptable compromise.

Working with a suspended physician:

It's actually easier to work with a nurse, student, intern, or unlicensed physician assistant (see Henry Dobson) than it is for an attending to work with a physician like House whose license is under suspension. Suspended physicians are not prohibited from working for hospitals or clinics, but there are a lot of restrictions. The first and foremost of these, which was criticized by many commentators on the episode, is that a suspended physician isn't allowed to see or examine a patient. What appears to be a throwaway line from Cuddy is a real legal requirement. If House was found to have seen the patient, that would have put both Foreman and the hospital as a whole in trouble. As the attending, Foreman is ultimately responsible for House's behavior in this respect.

Another prohibition is that a physician under suspension may perform lab tests, but is not permitted to interpret the results. They also can't prescribe drugs, which leaves all the decisions to Foreman.