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Just having a laugh

In the first of a series of articles, Daniel Sokol and Deborah Bowman consider the dangers of humour

Of all professionals, few are as fond of a good joke as doctors. Addressing medical students 80 years ago, William Osler encouraged his audience to “appreciate the inconceivably droll situations in which we catch our fellow creatures.”¹ He concluded: “Hilarity and good humour, a breezy cheerfulness . . . help enormously both in the study and in the practice of medicine.”¹

From first year medical students to retired consultants, all have laughed at the comedy of the human condition during the course of their clinical work. Thankfully, amid the sadness of illness and death lie fragments of comic gold. These precious moments of cheer punctuate the fundamentally serious role of healing the sick.

Wall of wit

Much has been written on why doctors and medical students use humour at work, especially offensive or cynical humour about patients.^{2 3} Some commentators believe that it is a protective mechanism against the horror and suffering before them; others think that it is an outlet for feelings of anger, frustration, or disgust towards certain patients (such as obese patients or those with conditions that are perceived to be self inflicted).⁴ An alternative view is that it creates a psychological barrier that prevents the carer from getting too attached to the patient,³ and another reason might be that it forges a bond between those privy to the joke. Humour reinforces a sense of togetherness.

In this short article, we shall not dwell on why medical students or doctors use humour, offensive or otherwise. Instead, we strive to tease out, through examples, why some types of humour are appropriate while others are morally troublesome.

Porn: never appropriate

A medical student examines a patient with a liver disorder. The patient is a 17 year old girl, who is accompanied by her mother. The student asks the patient if she has any tattoos. She says she does, and for some reason he asks for its location. She points to the lower part of her back. “Ah, a porn star tattoo!” he remarks with a smile. The girl and mother are aghast.

The student’s intention may have been to lighten the mood and put the patient at ease, but clearly it backfires. A comment that is appropriate to a friend may not be so to a stranger. We may mock close friends about their generously proportioned nose or their Homer Simpson-like hair, but only because we know, owing to shared history, that these amicable digs will not hurt them. In the above case, the reference to a porn star can easily be interpreted as offensive, as alluding to the sexual behaviour of the girl, and it is particularly insensitive when said to a young patient in front of her mother. Most people do not expect medical students or doctors to talk about pornography to their patients. The mother and daughter may infer from the remark that the student is a pornography connoisseur (how else would he know that it is a porn star tattoo?), and this may clash with their perception of medical professionals. The mother may be reluctant to let such a person examine her daughter, and the daughter may feel uncomfortable at the thought. The sexual reference risks blurring the line between clinical touch and intimacy.

The result of the comment, however innocently uttered, is that all parties are embarrassed, the mother and daughter are distressed, and the all important trust between student and patient is damaged. Finally, after such an incident, the patient and her mother may refuse to let medical students examine them in future, with consequent loss of training opportunities for fellow students.

The moral of the story is to think twice before sharing jokes with patients and, if humour is warranted, to avoid sexual references.

Unconscious respect

A morbidly obese patient is in theatre for an appendectomy. Once under anaesthetic, and before the incision, the operating registrar quips, “That’s why there’s not enough food in the world!” Laughter all around. James, a popular medical student, continues, “Wait, I think I can see a tin of biscuits under this fold of fat.” The staff are in stitches.

Unlike the previous scenario, the patient here is unconscious. He is not harmed by the comments. The registrar and the medical student are generating much laughter and creating an atmosphere of camaraderie. The benefits seem clear. So what, if anything, is wrong with the jokes?

Obese patients are common targets of disparaging humour.³ They are seen as responsible for their own condition, along with smokers, drug users, and alcoholics. Interviewed by Wear et al, one medical student said about obese patients, “You look at them in a disgusted way, like ‘you can’t take care of yourself, now I have to get all these other people to help me out, do a procedure for you and you’re probably not going to take care of yourself afterwards.’”³ The reality is that, although obese people are to some extent responsible, many other socioeconomic factors influence obesity, such as parents, the food industry, where you live (for example, whether you have to drive everywhere or whether your area is full of fast food restaurants), your type of work (sedentary or physical), psychological states (such as depression after an unexpected death), and a host of other societal factors.

Humorous but cynical comments about obese patients perpetuate the belief that obese people are entirely to blame for their predicament, ignoring environmental and biological factors. This prejudicial belief can lead, even subconsciously, to a lower standard of medical care. In the United States, evidence shows that doctors provide suboptimal treatment to African American, American Indian, and Hispanic patients compared with white American patients, undertreating minority patients, underestimating their pain, and engaging in more perfunctory interactions.⁵⁶⁷ Once doctors are aware that social biases can have a negative influence on patient care, even in those who claim to be immune to bias, they should avoid humour that can create or reinforce these biases in themselves and others (in the case above, to the entire operating room staff).

Spitting grave

Another reason why the registrar and student’s obesity jokes are ethically questionable is because they suggest a disrespectful attitude towards the patient and obese persons in general. The patient’s humanity seems to be lost with his consciousness. Even when an act causes no harm, it can still be objectionable. Consider a person who enjoys walking in graveyards at night, when all is quiet, and spits on people’s graves. With no witnesses, he causes no harm or distress (in fact, he derives much pleasure from it), yet we still view him in a negative light. The reason is that his action reflects poorly on his character. No morally virtuous person would spit on the graves of strangers for fun. Similarly, in their crassness, the comments of our two medics reveal something unpalatable about their characters.

Although the remarks do not offend the anaesthetised patient, they may well offend some of the nurses, operating room technicians, or other members of the medical team, whose polite laughter may disguise upset. One of the key duties of a doctor, according to the UK’s General Medical Council, is to “treat patients as individuals and respect their dignity.” The GMC also urges doctors working in teams to “act as a positive role model and try to motivate and inspire your colleagues.”⁸ The “fat” jokes can thus be seen as a failure of professionalism: they undermine patient dignity and, especially when uttered by a senior surgical registrar and a popular medical student, set a bad example to others.

Finally, this type of humour can adversely affect the jokers themselves, by weakening their sense of empathy and compassion. As McCrary and Christensen have suggested, such remarks have a “corrosive effect on the character of the health care team as a whole” and “a morally diminishing effect on the practice and attitudes of physicians.”⁹

Cherishing comedy

Far from wanting to banish all humorous banter from medicine we, like William Osler, encourage medical students to cherish the comedy inherent in much of their clinical work. As the French writer and physician François Rabelais noted so long ago, laughter is the property of man.¹⁰ Yet, for all its merriment, humour can also have a dark side, especially in the medical context, where patients are sick and vulnerable and relatives are anxious. When inappropriate, it can represent an affront to human dignity, to personal integrity, to public trust in clinicians, and to the feelings of patients, relatives, and colleagues, and it can even subtly create or perpetuate biases with adverse knock-on effects on patient care. A touch of common sense, of social sensitivity, is all it takes to avoid these ills.

“The patient here is unconscious. He is not harmed by the comments. So what, if anything, is wrong with the jokes?”

We thank Samantha Hettige and Ronald Sokol for helpful comments on an earlier draft.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

Daniel Sokol lecturer in medical ethics and law
daniel.sokol@talk21.com
Deborah Bowman senior lecturer in medical ethics and law Centre for Medical and Healthcare Education, St George’s, University of London, London
Student BMJ 2009;17:001-036-ISSN 0966-6494 | January 2009

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