It’s Just a Joke

Or, Humor From the Hospital Gallows

“It was 3:00 AM and three tired emergency room residents were wondering why the pizza they’d ordered hadn’t come yet. A nurse interrupted their pizza complaints with a shout: “GSW Trauma One—no pulse, no blood pressure.” The residents rushed to meet the gurney and immediately recognized the unconscious shooting victim: he was the teenage delivery boy from their favorite all-night restaurant, and he’d been mugged bringing their dinner. That made them work even harder. A surgeon cracked the kid’s rib cage and exposed his heart, but the bullet had torn it open and they couldn’t even stabilize him for the OR. After forty minutes of resuscitation they called it: time of death, 4:00 a.m. The young doctors shuffled into the temporarily empty waiting area. They sat in silence. Then David said what all three were thinking. “What happened to our pizza?” Joe found their pizza box where the delivery boy dropped it before he ran from his attackers. It was face up, a few steps away from the ER’s sliding doors. Joe set it on the table. They stared at it. Then one of the residents made a joke. “How much you think we ought to tip him?” The residents laughed. Then they ate the pizza.”

Katie Watson begins her essay on gallows humor with this true account from the life of a friend and physician. Fifteen years after the event, her friend still struggled with what had happened that night, not so much with the tragic death but with whether he and his colleagues were right to make a joke and laugh about it.

Watson grapples with different aspects of humor in general. Laughing together builds community. Telling a joke allows one to share truth that might otherwise be poorly received (and short circuits our capacity to argue with it). It allows us to cope with hard things. Many jokes have a “backstage” context to them - “not only did you have to be there, but you also had to be ‘us.’” Someone else, lacking all the necessary context, might be horrifically offended. Can you imagine the victim’s family hearing this joke?

Watson also highlights the role of power in a joke:

“When someone wonders if ‘it was wrong to make a joke’ backstage, perhaps they are really asking about the use and abuse of the power that comes with asserting oneself as the (comic) narrator of someone else’s tragedy. But a sophisticated analysis of power and humor includes assessment of relative power. This is captured in the concept of “joking up”—the idea that it’s okay for the less powerful to make fun of more powerful individuals or groups, but the reverse (joking down) is not. Joking up is what allows medical students to publicly mock their professors in the annual variety show; joking down is why professors doing a show that mocked students would be shocking.”

But aren’t physicians joking down when they make jokes about their patients? Watson responds, “…when physicians need to change patient behavior instead of biology, they often feel powerless to heal. If people who need (and resist) behavior changes are framed as patients like any other, then physicians are framed as failures. By reframing these people as less than full patients, derisive joking does the unspoken work of reframing physicians as blameless for their inability to help.”

That doesn’t make it right, but it does shed some light on why this kind of humor might become a powerful coping mechanism.

That doesn’t seem to be what happened with this particular joke. We need to be careful to identify the true butt of the joke. Was it the dead delivery boy? Watson claims it wasn’t. The butt of the joke was death itself: “‘How much you think we ought to tip him?’ is a macabre summary of all that’s owed in this world and all that can never be repaid. And it looks forward—it’s a moving-on question. In a situation that horrific and absurd, a joke is the rock you throw after the bad guy’s already gone—an admission of loss, and a promise to fight again another day.”

Watson outlines several questions that could be used to help one discern whether a joke is appropriate or not. The questions are helpful, but I want to zero in on one particular unexplored area: the relationship between humor and hope.

Hoping For More

Citing the work of Thomas Kuhlman, Watson writes, “…gallows humor ‘flourishes when all else fails and where there is no reasonable hope for improvement,’ and that one characteristic of such settings or moments is existential incongruity—‘a senseless hopeless aspect that justifies the psychological shift from a goal-directed frame of mind to a playful one.’”

When all else fails, at least we can laugh. Or, I’m laughing to keep from crying. At least we can move on with a smirk; crying grabs us and sits us down. In a situation where we feel we still need to act despite hopeless circumstances, gallows humor might prod us forward. It might make us a little more brazen. On the flip side, we’re not likely to joke about our hopes (at least those in the life-or-death dilemmas found in medicine). If we think what we’re hoping for is within reach, there’s no playing around; we strive. The residents weren’t laughing during their resuscitation attempt.

I've painted the poles a little starkly knowing there’s room in the middle for gradations of ambivalence. Such is our reaction to absurdity and suffering sometimes. But does humor help us to sustain hope?

It seems the joke allowed the residents to move on from a terrible a tragedy to finish the rest of their shift. They couldn’t stop working and mourn for the rest of the night even if they had wanted to. Other patients needed them; not only for their expertise, but for their hope. So the joke maybe helped them in that brief way.

But I also doubt any of them meditated on this joke the way Watson has. She was able to gift her reflection to her friend and maybe assuage some of the discomfort he had felt those many years. Perhaps totally unmitigated, unreflective gallows humor can have a corrosive effect on someone’s morale.

Let’s make the residents’ situation even more absurd: suppose they were practicing in a war zone and every other patient had suffered a horrific injury and died. Almost every patient summoned a dark joke. Now, on the one hand, if it doesn’t degrade their technical expertise, then what’s there to complain about? It helps them work. But on the other hand, these residents aren’t machines. If there’s only gallows humor with no reprieve, the situation might devolve in short order to The House of God. But this could just as easily describe M*A*S*H, where clinicians work like crazy to pull wounded soldiers during the Korean War “out of the sausage grinder,” as Hawkeye puts it. What separates M*A*S*H from The House of God are the periods of humanity and reflection that punctuate the humor in M*A*S*H.

I wonder then if the key is to not let the joke go. Gallows humor isn’t silly for the sake of silliness; it’s telling us something, as Watson argues. It’s silly to dissect a silly joke. It might be humanizing and even necessary to dissect a joke made from the gallows. Insofar as we want to avoid that, it might flag emotions that need to be honored (alone or with others), dilemmas that need to be acknowledged, or even power plays that need to be seen for what they are (e.g., making a joke to bypass making an argument).

So, yeah. Laugh now, ask questions later. But be sure to ask the questions.