Is gallows humor in medicine wrong?

The author, Katie Watson, bridges the worlds of medical ethics and comedy: she is an assistant professor in the Medical Humanities and Bioethics Program at the Feinberg School of Medicine at Northwestern University and she teaches improvisation and writing at The Second City Training Center in Chicago. What prompted her to explore the ethics of gallows humor in medicine was the story a doctor friend told her in which, years earlier, he and other residents tried unsuccessfully to save a teenage pizza delivery boy who had been shot while delivering their dinner.

After finding the pizza box where the boy dropped it before running from his attackers, one of the residents made a joke: "How much you think we ought to tip him?" The residents laughed, and then ate the pizza.

"Was it wrong to make a joke?" the doctor asked.

This question intrigued Watson as a bioethicist, she says, "because it is about moral distress, power imbalances between doctors and patients, and good people making surprising choices."

While there is a lot of literature on humor in medicine generally, particularly about clinician-patient interactions and the health benefits of laughter, she says there is relatively little that addresses gallows humor in medicine, which usually occurs between health care providers, and treats serious, frightening, or painful subject matter in a light or satirical way.

"The claim that being a physician is so difficult that 'anything goes' backstage misuses the concept of coping as cover for cruelty, or as an excuse for not addressing maladaptive responses to pain," Watson writes. "However, blanket dismissals of gallows humor as unprofessional misunderstand or undervalue the psychological, social, cognitive, and linguistic ways that joking and laughing work. Physicians deserve a more nuanced analysis of intent and impact in discussions of when gallows humor should be discouraged or condemned in the medical workplace."

Watson's analysis draws on literature from the humanities and social sciences on why we joke and on various uses of humor, including "backstage" humor that serves as a bonding and coping mechanism among insiders and "bullying jokes." She also observes changing standards in the backstage humor of doctors and medical students -- whereas "cadaver antics," in which medical students clowned around with body parts, were once a rite of passage, today they are "rarely tolerated, and the modern approach frames cadavers as former people."

Deciding when gallows humor is okay, Watson says, turns on the ethical question, When is joking a form of abuse -- of a patient, of trust, or of power? A joke about a patient's condition told in front of the patient or the patient's family is unethical because it has the potential to harm them. But she concludes that the tip joke was not wrong. "To me, the butt of the doctors' tip joke is not the patient. It's death," she writes.

Not only did the joke not harm anyone, she adds, it may have helped the residents "integrate this terrible event and get through the shift." In so doing, the joke may also have helped the next patient get the best possible care.