This post is a part of our Bioethics in the News series. For more information, click here.
By Tom Tomlinson, PhD
In mid-August this year, the Annals of Internal Medicine published an anonymously-written commentary titled “Our Family Secrets.” It describes in almost lurid detail the “joking” antics of some male surgeons caring for unconscious or sedated women undergoing surgery or childbirth. Since this is a family blog, I won’t provide the details. Readers can see for themselves. Suffice it to say that the behavior involved was nasty and despicable enough to attract a good deal of shocked media attention.
Part of the shock among the public was that these things were done as jokes, and reportedly every one present had a good laugh, except for the patients. For health care providers, however, this comes as no surprise. Dark humor of all kinds is very common among medical insiders. The examples reported in the Annals article stand at one extreme pole of a spectrum and were egregiously unethical. The question they raise for me is whether there are places further down the spectrum where dark humor—even when it has patients as its objects—is ethically acceptable.
Many people think the answer is “no.” A virtuous professional should never laugh at or about patients and their conditions. There’s nothing funny about illness or its treatment. Humor about patients is usually derogatory or cynical (Aultman).
But I don’t think this is right. Dark humor is inherent to the nature of medical work. And while some of it will be utterly objectionable, some of it will be ethically acceptable. The trick is how to tell the difference.
So what is “dark humor?” I like a Wikipedia entry’s take on it. “Humor in which topics and events that are usually regarded as taboo or tragic, or otherwise “nothing to laugh at,” are treated in an unusually humorous or satirical manner while retaining their seriousness. The effect of dark humor, therefore, is for the audience to experience both laughter and discomfort, often simultaneously” (adapted from the Wikipedia entry). Here’s an innocuous example.
What I especially like about this definition is the last part. First, it’s a clue to why we often find dark humor very funny. The laughter is first a response to the surprising incongruity between the perspective created by the comment or joke, and the actual situation. But second, the laughter serves as a release of the psychological tension between the pleasure the joke gives us, and our simultaneous feeling that we really shouldn’t laugh in the circumstances.
This definition also captures the source of dark humor’s ethical ambivalence. On the one hand, we generally think that wit, humor and laughter are natural, pleasurable, expressions of our human intelligence. But on the other, we think we should remain fully open to the tragedy before us, and the vulnerability of those who are undergoing it. But can we do both? That’s the ethical challenge.
So let me offer some examples along the spectrum, starting at the more benign end:
Jiffy: At M&M the resident presented the surgical challenges raised in the case of a psychiatric patient who had managed to insert a jar of peanut butter in his rectum. At the conclusion of his presentation, he asked if there were any questions.
After a long silence, someone in the back of the room demanded to know, “Well, was it smooth, or crunchy?”
The unexpected death: “I was visiting a ward at night, having been requested to see an old man who was about to die. Death was expected, we had made sure he was peaceful and comfortable, and the nurse and I stood by the bed watching him. Then, from the opposite end of the ward, we heard a dull thud. A patient had just fallen out of bed, stone cold dead. Nothing funny in that, you might think. And, no, in the cold light of day, it’s tragic. But at the time, we thought it was amusing” (chrispitts).
Doctor, your patient is on fire: “The evening’s theme: funniest beeper pages in the middle of the night… Another hilarious page: “Doctor, your patient is on fire.” The man in question was psychiatrically unstable and had ignited himself. We were howling in between spoonfuls of ice cream” (Sobel).
One might think that Jiffy is objectionable because it’s making fun of the patient. But that misunderstands the joke, which is parodying the formal conventions of morbidity and mortality rounds, rather than deriding the patient. It’s not mean, just raunchy.
One might also think that it’s just not funny when someone drops dead unexpectedly. Indeed not. But the death is not what provoked the laughter. The laughter was triggered by the sudden ironic incongruity presented by the situation.
And of course it is never funny when someone sets himself on fire. But it’s not the patient that’s funny. It’s the page. The first thing that springs to mind is those reports of spontaneous human combustion.
So how about the other end, closer to “Our Family Secrets?”
400 pounders: On one surgery service, morbidly obese patients were routinely referred to as “400-pounders.” This would always make one medical student giggle.
Wacko: A medical student was shadowing a family physician who was counseling a diabetic patient. The patient began to recount all the difficulties she had in her personal life. The physician was doodling on a pad, appearing to take notes. As the patient continued, the physician wrote “wacko” and showed the pad to the student sitting behind him, as if sharing important information.
These obviously are directed against the patient.
If “400 pounder” provokes laughter, it’s because it pictures the patient as a slab of meat or a carcass. And it’s dehumanizing of obese patients is all the more insidious once it becomes a routine way of talking. No longer funny– if it ever was– it institutionalizes an attitude or perspective about patients. This poses higher risks to the quality of patient care from sheer repetition. And its routine and unreflective use encourages a coarsening of sensitivity in the provider.
“Wacko” doesn’t even have the redeeming feature of being funny, at least not among those older than 10. It’s just mean, and teaching future physicians to be mean to boot.
As a fan of dark humor, I don’t want to ban it from health care. Human beings are born to be funny, laughter feels good, and it’s a wonderful way to relieve tension. The trick is deciding when to laugh, and when to wince.
If any of you have examples, please post them…and explain where you think they lie on the spectrum.
Tom Tomlinson, PhD, is Director of the Center for Ethics and Humanities in the Life Sciences and a Professor in the Department of Philosophy at Michigan State University.
Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Tuesday, October 13, 2015. With your participation, we hope to create discussions rich with insights from diverse perspectives.