Good Jokes, Bad Jokes: The Ethics of Nurses’ Use of Humor

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“Nurses make fun of their dying patients. That’s okay.” That was the provocative title of an op-ed by Alexandra Robbins in the Washington Post on April 16. The author’s treatment of the topic was more complex than the title suggested, but some examples of humor given in the article were troubling.

For ethical practice, nurses must consider if it is ever appropriate to discuss the clinical care of patients for humorous purposes. An easy answer would be—never. If patient care is never joked about, then no one’s feelings are ever hurt and nothing inappropriate is said as a joke. However, my experience as a nurse in psychiatric emergency and with human nature suggests two arguments against this approach:

• Jokes will be made despite any prohibition.
• Considerable good comes from such humor.

If jokes are going to be told anyway, it’s better to provide an ethical framework than to turn a blind eye. If joking about patient care is sometimes acceptable and sometimes not, nurses’ jokes are more likely to stay ethical if they consider in advance under what conditions it’s ethical to joke and how one distinguishes ethical from unethical humor.

According to Vaillant (1992), humor is among the most mature of the defenses. “Like hope, humor permits one to bear and yet to focus upon what is too terrible to be borne” (Vaillant, 1977). Those who have experienced the stress of intense clinical practice know the value of finding humor in life’s tragedies. In addition, patients who are able to cope with their physical and emotional pain are often those who find the humor in tragedy.

Still, some attempts to make people laugh are unkind, and it hurts to be the subject of others’ laughter. Vaillant distinguishes humor from wit, noting that humor never excludes (1977). It may help nurses to enjoy the beneficial effects of humor and avoid the effects of harmful humor if we attempt to identify some characteristics of appropriate humor. Watson (2011) offers some useful suggestions for self-examination to determine the acceptability of clinical humor:

• Is the joke about the patient, the situation, or the clinicians themselves?
• Does the joke reveal disdain or contempt for the patient?
• Could the joke affect care? An example might be jokes suggesting that a patient deserves pain or disability. Wear et al. (2006) demonstrated that medical students treated patients considered responsible for their pathology as “fair game” for derogatory humor. And nurses have more difficulty empathizing with patients they consider responsible for their pathology (Olsen, 1997). Therefore, jokes enhancing this perception could erode a nurse’s relationship with that patient.
• What is the underlying intent of the joke—is the motive to influence clinician behavior or attitude? This includes both harmful and helpful intent. Some jokes could be used to gently chide a clinician toward more empathy. Upon hearing a nurse refer to drug-seeking patients in a derogatory tone, I may retort, “Of course they’re lying about their pain. What would happen if she told the triage nurse that she has a five-bag-a-day habit and her dealer is out of town?” The comment generally gets a laugh, and my goal is to give the nurse a chance to consider the patient’s perspective and perhaps see the situation less as despicable deception and more as the desperation of unmet needs.
• Is it true humor—that is, is it inclusive, a clever juxtaposition, insightful—or is it simply mean-spirited mockery of another’s misfortune? This distinction is subtle and is often dependent on personal intuitive reaction: Does it feel cruel, callous or uncaring? Do you feel shame at saying or hearing it? Does laughing at the joke make you uncomfortable? These reactions vary widely, as can be seen in the public debate regarding what is called “political correctness.”

Filter yourself when thinking to tell a joke and reacting to another’s humor. Pause a moment before telling the joke or reacting to another’s comment; let your intuition and values weigh in. Then, speak—or don’t.

A more difficult ethical issue is whether it is acceptable to make potentially hurtful jokes if one can reasonably ensure that the joke remains within the clinical circle. This is problematic because it is difficult to predict who will be offended by what. To avoid negative consequences of clinical humor, nurses should be careful about the context:

• Don’t use clinical humor with nonclinicians at social gatherings.
• Never post anything online in social media making fun of a patient, even with attempts to deidentify. Belittling patients or making them the butt of mean-spirited humor in any context is unprofessional, suggesting an unethical approach to relationships.

Having said this, it’s also true that the line between appropriate and mean-spirited can be fuzzy; a nurse with intimate familiarity of a situation as part of their daily working life will have a different perspective regarding the spirit of a joke than a family member. Within a circle of colleagues, a person making a joke is known and can be judged on a broad basis instead of in terms of a single remark made outside the context of the jokester’s overall approach to practice.

In addition, when a joke is told among colleagues familiar with each other, clinicians can help each other stay within the bounds of ethical humor by speaking up and gently pointing out when a joke goes too far.

Sharing real humor is an effective and mature way to digest and accept the inevitable tragic and painful aspects of the human condition. Nurses deserve all appropriate tools available to handle the daily experience of witnessing and participating in human suffering.

References
Olsen, D. (1997). When the patient causes the problem: The effect of patient responsibility on the nurse–patient relationship. Journal of Advanced Nursing, 26, 515-522.

Vaillant, G. (1977) Adaptation to Life. Cambridge, MA: Harvard University Press.

Vaillant, G. (1992). Ego Mechanisms of Defense. Washington, DC: American Psychiatric Press.

Watson, (2011). Gallows humor in medicine. Hastings Center Report, 41(5), 37-45.

Wear et al. (2006). Making fun of patients: medical students’ perceptions and use of derogatory and cynical humor in clinical settings. Academic Medicine, 81(5), 454-462.