The consequences of gallows humour within the medical profession

Lewis M Cohen, MD, Professor of Psychiatry at Tufts University School of Medicine, contends that accusations of murder and euthanasia levelled at medical professionals – whether made genuinely or in jest – reflect conflicting societal beliefs concerning end-of-life patient care. In a commentary published in this month’s issue of Mayo Clinic Proceedings, Dr Cohen also asks whether gallows humour amongst medical professionals might be encouraging such accusations.

I had the opportunity to speak to Dr Cohen about the conflicting societal attitudes that surround end-of-life care, and to gauge his opinion of how gallows humour manifests itself within the medical profession. I began by asking him whether such humour was prevalent amongst physicians.

"It’s not only prevalent, it is lifesaving," he replied. "Gallows humour is a means by which we maintain our sanity in a world that often threatens to become insane. Samuel Shem’s bestseller The House of God tapped into this issue and exposed it to the public. Gallows humour has been part of the medical world for as long as I’ve been in it."

Dr Cohen went on to provide further details about the psychological purpose that gallows humour serves.

"Medical professionals are confronted with horrors every day," he explained. "These things are completely natural and yet we encounter them in such unfiltered ways that we need humour to help us to carry on. This is particularly true when it comes to death and dealing with the terrors that we all instinctively feel. Humour can be lifesaving."

I asked Dr Cohen about the ways in which accusations of euthanasia and murder levelled at physicians reflect conflicting societal beliefs concerning end-of-life patient care. As he explained, the enhanced ability to prolong life does not always bring with it the capacity to improve a patient’s quality of life.

"I think that there has been a sea change in terms of how medicine approaches end-of-life situations and end-of-life care," said Dr Cohen. "This has taken place over the last 20 years or so. Previously, there really wasn’t all that much that we could do at this stage, but whatever we could do, we did. Over time, we gained access to a wide range of new technological advances that enabled us to do some pretty gargantuan things in terms keeping people alive. In turn, there was a kickback reaction as people started to realise that we could go overboard in this respect. The palliative care philosophy proposes that prolonging life should not be the be-all and end-all, and that we should be more accepting of the fact that people die. It states that we should provide death, if we can, on a patient’s own terms."

In his commentary, Dr Cohen raises the question of whether the use of gallows humour within the medical profession might be encouraging accusations of euthanasia and murder. I asked Dr Cohen whether he believed that this was happening.

"No, to the contrary," he replied. "I think of humour as being a safety valve. It is a way of letting some steam out of the system. Medical professionals struggle over these issues both with each other and within themselves. Is it right for us to prolong life? Is it right for us to hasten somebody’s death by not doing some of the things that we might otherwise be doing? These are real tensions and I think that humour is a way of dealing with these tensions."

I concluded our interview by asking Dr Cohen whether or not he thought that physicians and nurses should modify their behaviour in relation to gallows humour. In his opinion, it is more important for medical professionals to address the underlying conflicts that surround end-of-life care.

"The behavioural change that is called for is for us to recognise these conflicts," explained Dr Cohen. "I do not think that medical professionals have really come to grips with the fact that within their own community, there exist strong disagreements over end-of-life care. We need to encourage a more open discussion of these disagreements. Doing so might enable us to take more steam out of the system. Humour is fine but if it does lead to genuine accusations, we have a problem. We cannot afford to arrive at a situation in which medical professionals, who are simply trying to relieve suffering by providing palliative care, are accused of murder. This is something that we have to prevent."