inherent Psychological biases

The article below presents an interesting experiment in assumption and bias.

A Magician’s Best Trick: Revealing a Basic Human Bias
An encounter with a magician reveals a lesson: Think critically about whether you’re only intermittently thinking critically

By ROBERT SAPOLSKY
Dec. 31, 2014 12:01 p.m. ET

My family and I recently watched a magician perform. He was not of the sleight-of-hand ilk but, instead, had a stunning ability to psychologically manipulate his audience into doing and thinking what he wanted: con man as performance artist. He was amazing.

Afterward, we had the fortune of talking about neuroscience and psychology with him. In the process, he offered a demonstration of a small building-block of his craft.

The Magician gave a dime to a volunteer, my son, instructing him to hide it in one of his hands behind his back. The Magician would then guess which hand held the dime. He claimed that if you’re attuned to subtleties in people’s behavior, you can guess correctly at way above chance levels.

Not that day, though. The Magician wasn’t doing so hot. After a string of wrong guesses, he mumbled to my son, “Hmm, you’re hard to read. More rounds, and The Magician was only running 50-50.

They traded roles. And my son turned out to be really good at this game. The Magician looked impressed. After a stretch of correct guesses, he asked: “Did you play rock/paper/scissors when you were a kid?”

“Yes,” my son said.

“Were you good at it?”

“I suppose so.”

“Ah, makes sense, there are similar skills involved.”

Another string of successful guesses; we were agog. The Magician, looking mighty alert, asked: “So, are you trying to imagine what I’m thinking? Or are you focusing on my facial expressions? Or on something I’m doing with my hands?”

The near perfect streak continued; we were flabbergasted. Finally, another guess by my son—“I’m guessing it’s in your right hand.” The Magician opened his right hand displaying a dime. And then opened his left hand, which contained…another dime.

We dissolved with laughter, seeing what dupes we were. Ohhh, he had dimes in both hands the whole time. We started imagining cons built on manipulating a mark into believing that he has an otherworldly skill at something unexpected, and then somehow exploiting that false belief.

The guy had played us every step of the way. First, there was his “poor” performance at guessing—hey, we concluded, this guy puts on his pants one leg at a time. Then he complimented my son with “Hmm, you’re hard to read.” Next, The Magician gave a plausible explanation for my son’s success: “The experience with rock/paper/scissors, of course.” Finally, as my son’s run continued, The Magician indicated it was now a given that my son was virtuosic at this game: The point now was to analyze how he was doing it. Hook, line and sinker.

Something was painfully obvious. If my son had had a string of failures, with the hand containing no dime, we would have instantly used Critical Thinking 101, saying to the magician: “Hey, open your other hand, let’s make sure both hands aren’t empty.”

But faced with this string of successes, it never occurred to us to say. “Let’s make sure you don’t also have a dime in that other hand.” Instead, I had been thinking: “Wow, my son turns out to be the Chosen One of dime-guessing; my wife and I now have the heavy responsibility of ensuring that he only uses his gift for good; he’ll usher in world peace with his ability; he’ll…”

No wonder I’m embarrassed.

It’s what psychologists call “confirmation bias”: remembering information that supports your opinion better than information doing the opposite; testing things in a way that can only support, rather than negate, your hypothesis; and—the variant we fell for—being less skeptical about outcomes we like than we would about less-pleasing results.

Confirmation bias infests diplomacy, politics, finance and everyday life. This experience offered some wonderful lessons: Think critically about whether you’re only intermittently thinking critically; beware of Ponzis bearing gifts; always examine the mouth and the other hand of a gift horse.

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Why we eat spicy foods

I guess I now have a better understanding of my enjoyment of spicy food and my regular use of hot sauce.  The WSJ has a piece in its weekend review called “Why We Love the Pain of Spicy Food.”  Though, I can honestly say I do have a limit to the amount of spice I am willing to try.  I am not one to want excessive risk and pain, just a kick to my taste-buds.

Why We Love the Pain of Spicy Food
Eating hot chili peppers allows us to court danger without risk, activating areas of the brain related to both pleasure and pain.

By JOHN MCQUAID
Dec. 31, 2014 2:10 p.m. ET

As winter settles in and temperatures plunge, people turn to food and drink to provide a little warmth and comfort. In recent years, an unconventional type of warmth has elbowed its way onto more menus: the bite of chili peppers, whether from the red jalapeños of Sriracha sauce, dolloped on tacos or Vietnamese noodles, or from the dried ancho or cayenne peppers that give a bracing kick to Mayan hot chocolate.

But the chili sensation isn’t just warm: It hurts! It is a form of pain and irritation. There’s no obvious biological reason why humans should tolerate it, let alone seek it out and enjoy it. For centuries, humans have eagerly consumed capsaicin—the molecule that generates the heat sensation—even though nature seems to have created it to repel us.

Like our affection for a hint of bitterness in cuisine, our love of spicy heat is the result of conditioning. The chili sensation mimics that of physical heat, which has been a constant element of flavor since the invention of the cooking fire: We have evolved to like hot food. The chili sensation also resembles that of cold, which is unpleasant to the skin but pleasurable in drinks and ice cream, probably because we have developed an association between cooling off and the slaking of thirst. But there’s more to it than that.

Paul Rozin, a professor of psychology at the University of Pennsylvania, became interested in our taste for heat in the 1970s, when he began to wonder why certain cultures favor highly spicy foods. He traveled to a village in Oaxaca, in southern Mexico, to investigate, focusing on the differences between humans and animals. The residents there ate a diet heavy in chili-spiced food. Had their pigs and dogs also picked up a taste for it?

“I asked people in the village if they knew of any animals that liked hot pepper,” Dr. Rozin said in an interview. “They thought that was hilariously funny. They said: No animals like hot pepper!” He tested that observation, giving pigs and dogs there a choice between an unspicy cheese cracker and one laced with hot sauce. They would eat both snacks, but they always chose the mild cracker first.

Next, Dr. Rozin tried to condition rats to like chilies. If he could get them to choose spicy snacks over bland ones, it would show that the presence of heat in cuisine was probably a straightforward matter of adaptation. He fed one group of rats a peppery diet from birth; another group had chili gradually added to its meals. Both groups continued to prefer nonspicy food. He spiked pepper-free food with a compound to make the rats sick, so they would later find it disgusting—but they still chose it over chili-laced food. He induced a vitamin-B deficiency in some rats, causing various heart, lung and muscular problems, then nursed them back to health with chili-flavored food: This reduced but didn’t eliminate their aversion to heat.

In the end, only rats whose capsaicin-sensing ability had been destroyed truly lost their aversion to it. Dr. Rozin came to believe that something unique to humanity, some hidden dynamic in culture or psychology, was responsible for our love of chili’s burn. For some reason apparently unrelated to survival, humans condition themselves to make an aversion gratifying.

Not long after, Dr. Rozin compared the tolerances of a group of Americans with limited heat in their diets to the Mexican villagers’ tastes. He fed each group corn snacks flavored with differing amounts of chili pepper, asking them to rank when the taste became optimal and when it became unbearable.

Predictably, the Mexicans tolerated heat better than the Americans. But for both groups, the difference between “just right” and “ouch” was razor-thin. “The hotness level they liked the most was just below the level of unbearable pain,” Dr. Rozin said. “So that led me to think that the pain itself was involved: They were pushing the limits, and that was part of the phenomenon.”

In the human brain, sensations of pleasure and aversion closely overlap. They both rely on nerves in the brainstem, indicating their ancient origins as reflexes. They both tap into the brain’s system of dopamine neurons, which shapes motivation. They activate similar higher-level cortical areas that influence perceptions and consciousness.

Anatomy also suggests that these two systems interact closely: In several brain structures, neurons responding to pain and pleasure lie close together, forming gradients from positive to negative. A lot of this cross talk takes place close to hedonic hot spots—areas that respond to endorphins released during stress, boosting pleasure.

The love of heat was nothing more than these two systems of pleasure and pain working together, Dr. Rozin concluded. Superhot tasters court danger and pain without risk, then feel relief when it ends. “People also come to like the fear and arousal produced by rides on roller coasters, parachute jumping, or horror movies,” he wrote in the journal Motivation and Emotion—as well as crying at sad movies and jumping into freezing water. “These ‘benignly masochistic’ activities, along with chili preference, seem to be uniquely human.” Eating hot peppers may literally be a form of masochism, an intentional soliciting of danger.

Dr. Rozin’s theory suggests that flavor has an unexpected emotional component: relief. A 2011 study led by Siri Leknes, a cognitive neuroscientist then at Oxford University, looked at the relationship of pleasure and relief to see if they were, in essence, the same. Dr. Leknes gave 18 volunteers two tasks while their brains were scanned: one pleasant, one unpleasant.

In the first task, they were asked to imagine a series of pleasurable experiences, including consuming their favorite meal or smelling a fresh sea breeze. In the other, they were given a visual signal that pain was coming, followed by a five-second burst of 120-degree heat from a device attached to their left arms—enough to be quite painful but not enough to cause a burn.

The scans showed that relief and pleasure were intertwined, overlapping in one area of the frontal cortex where perceptions and judgments form, and in another near the hedonic hot spots. As emotions, their intensity depended on many factors, including one’s attitude toward life. Volunteers who scored higher on a pessimism scale got a stronger surge of relief than did optimists, perhaps because they weren’t expecting the pain to end.

The world’s hottest chili, according to the Guinness World Records, is the Carolina Reaper, developed a few years ago by Ed Currie. His website features videos of people eating the peppers, and they are studies in torture. As one man tries a bite, his eyes open with surprise, then his chair tips back and he falls on the floor. Another sweats up a storm and appears to be suffering terribly, but presses on until he has eaten the whole thing.

Watching these, it’s clear that whatever enjoyment might be derived from savoring chili flavors, true satisfaction comes only in the aftermath: the relief at having endured, and survived.

—Adapted from Mr. McQuaid’s “Tasty: The Art and Science of What We Eat,” to be published on Jan. 13 by Scribner.

Why do lawyers get depressed?

I thought this would be something interesting for my lawyer friends to read.  Do you agree with the author? 

Martin E. P. Seligman, a psychologist and proponent of “positive psychology,” observes that lawyers experience depression at rates that are 3.6 times as high as that of other employed people. They also abuse alcohol and illegal drugs at rates above what’s seen in non-lawyers. Why is this? In part, he says, the law selects people with a glass-half-empty attitude. His research has found that people who score low on an optimism test do better in law school. “Pessimism,” he writes,

is seen as a plus among lawyers, because seeing troubles as pervasive and permanent is a component of what the law profession deems prudence. A prudent perspective enables a good lawyer to see every conceivable snare and catastrophe that might occur in any transaction. The ability to anticipate the whole range of problems and betrayals that non-lawyers are blind to is highly adaptive for the practicing lawyer who can, by so doing, help his clients defend against these far-fetched eventualities. If you don’t have this prudence to begin with, law school will seek to teach it to you. Unfortunately, though, a trait that makes you good at your profession does not always make you a happy human being.

To counter unhappiness in law firms — and more than half of all lawyers say they are dissatisfied with their jobs — Seligman proposes letting people spend five hours a week on tasks that play to personal strengths that are not always appreciated by the profession. The list of such qualities, however, is enough to make you run in the opposite direction from law school. “Take Samantha’s enthusiasm,” he writes, “a strength for which there is usually little use in law …”

Oy. His proposed solution is to have Samantha “work with the firm’s public relation agency on designing and writing promotional materials.”

Of course, it would be substantially cheaper to have communications professionals do the same work, which gets to the heart of the problem. Lawyers are well compensated for the work that makes them miserable. To the extent they move away from the work that is their firms’ bread and butter, the less they warrant the high salaries that offer (some) recompense for their unhappiness. Seligman offers more-plausible examples of ways that tasks in firms could be reshuffled to reduce the drudgery: Give an associate with a great deal of “valor” a break from drafting briefs and have him team up with a star litigator, for example, to prepare for an upcoming trial.

But surely such exciting work is in short supply; everyone would like the task Seligman mentions. I can’t help but be pessimistic about the prospects of reducing lawyerly negativity.

Shalit chronicles

I realize I am late to the party.  Part of this was purposeful in that I felt others had captured much of what was out there regarding the release of Gilad Shalit.  Yet, I came across three pieces over the weekend that made me decide it would be good to at least offer up some of the material online regarding how we should think about and react to his freedom.  Here are a couple of the more fascinating pieces I found (for some other headlines, check out Bruce’s Mideast Soundbites).

A Mother’s Pain – Sherri Mandel

Why are we against the exchange that allows murderers to go free? Because we know the suffering that they leave in their wake.

Why is it that terror victims are seemingly the only ones against the prisoner exchange? While other Israelis are rejoicing, we are in despair.

Arnold and Frimet Roth circulated a petition against the release of Ahlam Tamimi, an accomplice in their daughter Malki’s murder at the Sbarro pizza shop.

Tamimi says she is happy that many children were killed in the attack. Meir Schijveschuurder, whose family was massacred in the same attack, filed a petition with the high court and says he is going to leave Israel because of his feelings of betrayal. The parents of Yasmin Karisi feel that the state is dancing in their blood because Khalil Muhammad Abu Ulbah, who murdered their daughter and seven others by running them down with a bus at the Azor junction in 2001, is also on the list to be released. Twenty-six others were wounded in that attack.

Why are so many of us against the exchange that allows murderers and their accomplices to go free? Because we know the suffering that these murderers leave in their wake.

Yes, I want Gilad Schalit released. But not at any price. Not at the price we have experienced.

My son Koby Mandell and his friend Yosef Ish Ran were murdered by terrorists 10 years ago when they were 13 and 14 years old. They had been hiking in the wadi near our home when they were set upon by a Palestinian mob and stoned to death. It was a brutal, vicious murder.

We now run the Koby Mandell Foundation for terror victims’ families. We direct Camp Koby, a 10-day therapeutic sleep away camp for 400 children who have lost loved ones, mostly to terror. We also run mothers’ healing retreats and support groups.

MOST PEOPLE don’t understand the continuing devastation of grief: fathers who die of heart attacks, mothers who get sick with cancer, children who leave school, families whose only child was murdered. We see depression, suicide, symptoms of post traumatic stress disorder. You wouldn’t believe how many victims’ families are still on sleeping pills and anti-anxiety medication. We see the pain that doesn’t diminish with time. We literally see people die of grief.

Bereaved families face acute psychological isolation.

Nobody understands us, they often complain.

They mean that nobody understands the duration or the severity of their pain and longing. In the aftermath of a prisoner exchange, this isolation will only be exacerbated.

So will the feeling that our children’s deaths don’t matter.

When people tell me that my son Koby died for nothing, I always used to say: No, it is our job to make his death mean something.

But now I am not sure. It seems that the government is conspiring to ensure that our loved ones’ deaths were for nothing.

Cheapening our loved ones’ deaths only enhances the pain. If Israel is willing to free our loved ones’ murderers, then the rest of the world can look on and assume that the terrorists are really freedom fighters or militants. If Palestinians were murdering Jews in cold blood without justification, surely the Israeli government wouldn’t release them.

No sane government would.

When we were sitting shiva for Koby, a general in the army told us: “We will bring the killers to justice.” I believed him. I took his words to heart. Today I am thankful my son’s killers have not been found. So are my children. Of course, I don’t want the terrorists to kill again. But if they were to be released in this prisoner exchange, I don’t think I could bear it.

We don’t want other families to be put in our situation.

We don’t want terrorists to be free when our loved ones are six feet underground. Ten years after my son was beaten to death, the pain often feels like a prison. In many ways, I am not free.

We don’t want other terrorists to be emboldened because they know that even if they murder, they may not have to stay in prison. President Shimon Peres says he will pardon but he will not forgive. Terrorist victims’ families will not pardon or forgive the government for this release.

We have been betrayed. To pardon terrorists mocks our love and our pain.

Furthermore, terrorism aims to strike fear in an entire society, to bring a whole populace to its knees. During the intifada, the terrorists did not succeed in defeating Israeli society. But to release prisoners now signals to Hamas that their strategy of terror was correct, effective.

They will celebrate wholeheartedly because they have won.

And as a result of prisoner exchanges, the Israeli justice system can only be seen as a joke, a mockery, even a travesty of justice.

It provides no deterrent and no retribution. It’s as if our government says to the killers: Come hurt us again. We’ll be happy to release you one day. We’ll let you go when you demand it.

I want Gilad Schalit home.

We need to protect our own soldiers. But not with a wholesale prisoner exchange. I wish that I could rejoice with the Schalit family. But I can’t.

The price is too high.

The writer is the mother of Koby Mandell, who was stoned to death near his home in Tekoa in 2001.

‘Shalit release like resurrection of the dead’

Rabbi Ovadia Yosef expresses joy over kidnapped soldier’s return, says it illustrates what Jewish people should expect at End of Days by Kobi Nahshoni

Shas‘ spiritual leader, Rabbi Ovadia Yosef, says the release of kidnapped soldier Gilad Shalit is a sort of “preview” for the resurrection of the dead.

In a sermon delivered Tuesday night ahead of the holiday of Simchat Torah, the rabbi explained that the joy over Gilad’s return to his family illustrates what the Jewish people should expect at the End of Days, when the dead will rise out of their graves and return to life.

Yosef concluded his sermon by stating that “this is a great day of joy for all the people of Israel for Gilad Shalit’s return.”

“Every day we say (in a prayer), ‘Blessed is God, the resurrector of the dead’ – what a great joy we’ll experience. We are being described what will happen.”

According to the rabbi, the entire world was excited about the soldier’s release from captivity after five years, and in the future the dead will return to their families even decades after being taken away from them.

In a bid to demonstrate the great joy in the days of the Messiah, Rabbi Yosef explained that it would be like a multitude of weddings, as each person returning to life will have to remarry his widow in order to live with her again.

“Everywhere you go – a chuppah. This one’s wife has been resurrected, and that one’s wife has been resurrected – what a joy it will be!”

 

Rabbi Yosef followed Shalit’s return home on Tuesday, after being involved in the early stages of the prisoner exchange deal – offering support and encouragement. The rabbi stayed at home as usual and continued his Torah studies, but asked his family members to update him on every development.

Upon hearing that the soldier’s physical and mental condition was satisfactory, he excitedly recited the “Blessed is God that redeems and saves” prayer and said Jews must continue praying for his full recovery.

A Mitzvah Behind the Price of a Soldier’s Freedom By SAMUEL G. FREEDMAN

On the Sabbath morning of Nov. 5, less than three weeks after the release of Sgt. First Class Gilad Shalit in a prisoner exchange between Israel and Hamas, Jews in synagogues throughout the world will read a Torah portion concerning Abraham’s early journeys. The text recounts how invaders conquered the city of Sodom, taking Abraham’s nephew Lot as a captive, and the way Abraham raised an army to rescue him.

The timing of this Torah reading is an absolute coincidence, an unplanned synchronicity between the religious calendar and breaking news. Yet the passage also offers an essential explanation, one almost entirely ignored in coverage of the Shalit deal, for Israel’s anguished decision to pay a ransom in the form of more than a thousand Palestinian prisoners, including the perpetrators of terrorist attacks on civilians.

The story of Abraham saving Lot represents the earliest of a series of examples of the concept of “pidyon shvuyim” — redeeming the captives, invariably at a cost — in Jewish Scripture, rabbinic commentaries and legal codes. That concept, absorbed into the secular culture of the Israeli state and the Zionist movement, helped validate the steep, indeed controversial, price of Sergeant Shalit’s liberation.

Far from being some abstruse, obscure point of theology, pidyon shvuyim is called in the Talmud a “mitzvah rabbah,” a great commandment. The Shulhan Arukh, a legal code compiled in the 16th century, states, “Redeeming captives takes precedence over sustaining the poor and clothing them, and there is no commandment more important than redeeming captives.”

So while journalists, analysts and scholars have offered various motivations for the disproportionate deal — the effect of the Arab Spring, the institutional culture of the Israeli Army to never leave behind its wounded, the symbolism of Sergeant Shalit as everyone’s child in a country of nearly universal military service — the principle of pidyon shvuyim preceded all those factors.

“For most people in Israel, it doesn’t translate directly as a mitzvah, because even if they’re attached to Jewish tradition, they’re not halakhic,” said Noam Zohar, a professor of philosophy at Bar-Ilan University near Tel Aviv, using a term for following religious law. “But the underlying values — solidarity and the high value of every individual life — are part of our public ethos. The same values informed the high urgency of pidyon shvuyim.”

Moshe Halbertal, a philosophy professor at Hebrew University of Jerusalem, framed the issue similarly. “Those things are in the DNA of the culture,” he said of the religious teachings about ransoming captives. “It’s a sentiment that can’t be measured in exact legal or judicial terms. It plays a role in those moments of perplexity. You fall back on your basic identity. As a Jew, as an Israeli, what do I do?”

From its initial depiction in Genesis, the admonition to redeem captives reappears in the books of Leviticus and Nehemiah, as well as in the Talmud, Shulhan Arukh and writings of Maimonides. Among the ancient commentators, as well as among Israelis today, debate has persisted over whether pidyon shvuyim is an absolute value.

A passage in the Talmudic volume of Gittin, anticipating the recent voices of Israelis critical of the Shalit deal, cautions, “We do not redeem captives for more than their worth, so that enemies will not dedicate themselves to take other people captive.”

The traumas of Jewish history have provided innumerable opportunities for reconciling the tension between redemption and extortion. Throughout the Middle Ages, Jews who traveled as merchants and traders were frequently kidnapped by pirates or highway bandits. During the Holocaust, German forces routinely threatened to destroy Jewish communities unless the residents paid a pre-emptive ransom.

As Bradley Burston wrote last week in the Israeli newspaper Haaretz, over the past 54 years, the nation has freed a total of 13,509 Arab prisoners in exchanges that brought home 16 captive Israeli soldiers — a ratio of roughly 800 to 1.

With such an imbalance, pidyon shvuyim has been both a cherished and a contested belief. A prominent German rabbi taken captive in the 14th century, Meir ben Baruch, instructed his followers not to pay a ransom, which he feared would be onerously high, and ultimately was killed. Israel was torn apart in the 1950s by a libel trial involving Rudolf Kasztner, a Jewish activist in Hungary who had paid cash, gold and jewels to the Nazi officer Adolf Eichmann in 1944 to save about 1,600 Jews headed for death camps. So controversial were Mr. Kasztner’s actions that he was assassinated by a fellow Israeli more than a decade after the war.

While Israelis have widely believed that sovereignty and military might ended the need for paying ransoms, the Shalit deal has proven otherwise. It was approved by a prime minister, Benjamin Netanyahu, who had repeatedly written against what he termed “terrorist blackmail” earlier in his political career.

“The Zionist diagnosis, the post-Holocaust diagnosis, was that powerlessness invites victimization,” said Michael Berenbaum of the American Jewish University in Los Angeles, a prominent Holocaust historian. “What’s intriguing here is that power has not resolved Israel’s vulnerability.”

Indeed, as the Jewish ethicist Elliot N. Dorff pointed out, contemporary Israel is vulnerable in ways that the small, scattered communities of the Diaspora were not. It has its own enemy prisoners to be demanded in a trade. The Shalit negotiations took place in a constant media spotlight, tracking not just five years of failed deal making between Israel and Hamas but the tableau of Sergeant Shalit’s parents sitting in a protest tent outside Mr. Netanyahu’s office.

For all the practical, pragmatic, geopolitical calculations that went into the final deal, it also benefited from the endorsement of a leading Sephardic rabbi, Ovadia Yosef, the spiritual leader of the Shas Party. With his approval, the Shas members in Mr. Netanyahu’s cabinet voted for the deal. And, in an unspoken, little-noticed way, religious tradition informed a real-world decision.

“The whole issue of redeeming captives,” as Mr. Dorff put it, “has not been a theoretical one.”

The use of humor in Medicine

In a recent article in the Hastings Center Report, Katie Watson presents a discussion she calls “Gallows Humor in Medicine.”  The concept of laughter in the face of challenging situations is one we often face in Hospice work.  And we laugh and find humor in our work, often as a means of coping with the harsh realities of life.  Yet, her discussion tries to look at the subject through the eyes of whether it is ethically problematic to express humor in the face of other’s trauma.  The biggest insight I found in the entire article is that humor in the medical profession is actually decreasing.  She points out that residents don’t play as many tricks on fellow residents using cadavers, and as with other places, hazing is down as well.  For many, these trends are not positive, to which I would agree.  It is true that we shouldn’t laugh at all problems and traumas, but it is important to, at least internally, have some levity in the face of the sadness.  I have quoted for you the introduction and conclusions of her piece. 

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.

 

David told me this story fifteen years after he finished his residency, but the urgency with which he told it made it seem like it happened last night. “You’re the ethicist,” he said. “Was it wrong to make a joke?”

Gallows humor is humor that treats serious, frightening, or painful subject matter in a light or satirical way. Joking about death fits the term most literally, but making fun of life-threatening, disastrous, or terrifying situations fits the category as well. There is a fair amount of literature on humor in medicine generally, most of which is focused on humor in clinician-patient interactions or humor’s benefit to patients.1 There is relatively little specifically addressing the topic of this article: gallows humor in medicine, which usually occurs in interactions between health care providers.

Gallows humor is not a feel-good, Patch Adams kind of humor, but it is not synonymous with all cruel humor, either. As one physician put it, the difference between gallows humor and derogatory humor is like “the difference between whistling as you go through the graveyard and kicking over the gravestones.”2 Many health care providers witness or participate in gallows humor at some point. After reviewing over forty medical memoirs, Suzanne Poirier reports that “Anger and gallows humor are generally accepted forms of expression among undergraduate and graduate medical students . . . but expressions of serious self-doubt or grief are usually kept private or shared with only a trusted few.”3

David’s question intrigued me as a bioethicist because it is about moral distress, power imbalances between doctors and patients, and good people making surprising choices. But it also piqued my interest as someone who enjoys joking around—when not teaching bioethics, I teach improv and sketch writing at Second City, where I’m an adjunct faculty member. But David didn’t ask me if the tip joke was funny. He asked about it in ethics’ normative terms of right and wrong.

In this article, I consider whether some joking between medical professionals is actually unethical. The claim that being a physician is so difficult that “anything goes” backstage misuses the concept of coping as cover for cruelty, or as an excuse for not addressing maladaptive responses to pain. However, blanket dismissals of gallows humor as unprofessional misunderstand or undervalue the psychological, social, cognitive, and linguistic ways that joking and laughing work. Physicians deserve a more nuanced analysis of intent and impact in discussions of when gallows humor should be discouraged or condemned in the medical workplace. They also deserve deeper consideration of physician health than the professionalism lens might provide. Surely we can advocate for the humanity of patients without denying the humanity of those who treat them…

One of medical training’s first requirements is the violation of strong cultural taboos around death and dead bodies. Dissecting corpses has generated “cadaver antics” that many older physicians recall fondly—making jokes, clowning around with body parts, and pulling pranks to scare labmates. Joking like this helps turn corpses into cadavers by framing bodies as objects. Until recently, cadaver antics were a rite of passage, initiation, and enculturation into an ethos that said a doctor is a tough person who can laugh at death. Not just not cry about death. Laugh. Today cadaver antics are rarely tolerated, and the modern approach frames cadavers as former people. Students are commonly asked to imagine lives lived before these bodies died, and to journal or discuss their emotional reactions in small groups.26 Many classes end with a memorial service students create to thank the people they have dissected for donating their bodies, and sometimes they even meet the donor’s family members.27 The concept of performativity is helpful here: how must a person change the way she or he looks, acts, and feels to both perform the social role of doctor and to be recognized as one? The modern approach to anatomy lab represents a dramatic shift away from a macho joke-about-death performance of the role of doctor, and toward compassion and connection as being performative elements that help define the role of doctor.

The medical workplace may be changing, too. I’ve heard older physicians lament that the workplace is not as funny as it used to be, that practicing physicians do not joke around together like they used to. If that’s true, perhaps one reason is that the easy in-group joking they remember was based not just on being physicians, but on the broader bond of being straight white male physicians. The increasing diversification of medicine narrows the meaning of “it’s just us” to what’s truly distinctive about providing health care, versus simple differences in physician and patient demographics. It’s also possible that the dramatic increase in women physicians has unique effects on gallows humor. It’s a generalization rife with individual exceptions, but if there are differences in stereotypically male and female forms of humor, it stands to reason that the increased presence of women might cause a cultural shift in when and how backstage gallows humor is used in the workplace. This gender shift may also have made coping mechanisms that substitute for joking about fear and sadness (like verbal expressions of these emotions) more acceptable in the medical workplace.

I applaud the cadaver lab changes, and I strongly support the backstage changes that make a diverse workforce welcome. I also support efforts to define what I think of as HOG talk (“House of God talk”) as unprofessional because shallow bullying and derogatory slang coarsen the moral enterprise of medicine and cut providers off from healthier means of coping.

Yet in some areas, perhaps the hand wringing has gone too far. Condemnation of gallows humor is sometimes premised on a category mistake (such as lumping it together with all making fun of patients28) or a double standard. For example, an article titled “Humor in the Physician-Patient Encounter” contrasts a short treatment of “Destructive Gallows Humor” between providers, which frames all gallows humor as “‘sick’ wit and hurtful humor used to separate providers from patients,” with a long treatment of “Therapeutic Humor” between providers and patients, which is “grounded on a recognition of the human condition that is shared by patient and provider.”29 What the article fails to acknowledge is the human condition that is shared by provider and provider. Critics of backstage gallows humor who are admirably concerned with empathy for patients sometimes seem curiously devoid of empathy for physicians. Medicine is an odd profession, in which we ask ordinary people to act as if feces and vomit do not smell, unusual bodies are not at all remarkable, and death is not frightening. Moments when health care providers suddenly see the enormous gulf they’re straddling between medical and lay culture are one source of gallows humor. Being off-balance can make us laugh, and sometimes laughing is what keeps us from falling over.

Empathy for clinicians does not mean anything goes; it means clinicians must be conceptualized as human beings rather than as robotic systems for care delivery. Laughing and caring for others are both sources of joy. Suggesting physicians can only enjoy one of these pleasures in certain circumstances costs them something, and therefore deserves thoughtful justification.

Should They Joke?

Insights from the humanities and social sciences supply the context required to fully analyze David’s ethics question: Was it wrong to make the tip joke? When is behind-the-scenes gallows humor okay, and when should it cause concern? Underlying all this, the ethics question may be, “When is joking a form of abuse?”—abuse of a patient, abuse of trust, or abuse of power.

To answer, I would first want to think about who is harmed by the joking.30

 

  • Within the text of the joke, who or what is the true target? Does close reading reveal it to be a defenseless patient? Or is the joke really aimed at a doctor who is defenseless against death, decay, and chronic illness?
  • Could the joke harm the way future care is delivered? By using the power of humor to frame the patient in a way the patient cannot challenge, could the backstage joke bias listeners’ future interactions with that particular patient? Does the repetition of stereotyping jokes about “patients like these” contribute to making the health care provider calloused toward a particular demographic?
  • Could the joke harm the profession by diverting anger caused by structural problems (like caseloads so high that patients feel like the enemy, or scheduling that results in chronic sleep deprivation) and releasing it on the easy punching bag of patients rather than using it to make productive changes?
  • Who is listening to the joke? Gallows humor that seems ethical backstage can become unethical in front of patients, families, or others because it has the potential to harm them directly.

 

Next, I would want to ask about the health care provider’s relationship to the joking.

 

  • What’s the clinician’s underlying intent in joking? Is gallows humor being used as a helpful defense mechanism when circumstances limit the options for processing something difficult? Is the intent to get through the day by trying to lighten an oppressive situation, or is the intent to be a jolly bully?
  • What impact might this joking have on the clinician? Is it the type of joking that helps clinicians open up to difficult experiences or frees them from intolerable burdens? Or is it the type of joking that cuts clinicians off from experiences or patients that healthy clinicians should be able to engage with?
  • How often does the health care provider joke like this? If a doctor is joking about patients and death constantly, then (even if each can be justified individually) does she need help expanding her range of coping mechanisms? Or is this joking part of an ongoing pattern (say, of objectifying vulnerable patients) that suggests deeper provider biases?

 

David and his colleagues scattered across the country after residency, but in the fifteen years that passed before he told me the tip joke, they talked about the night the delivery boy died several times. The whole thing made them sad for years, he said. “Wasn’t that terrible?” they’d ask each other on the phone. “How could we eat the food that poor kid dropped?”

In the process of trying to do good, did they become bad? I do not think so.

To me, the butt of the doctors’ tip joke is not the patient. It’s death. The residents fought death with all they had, and death won. Patient care was not harmed—the patient in this case had received the best medical care they could deliver, and he was dead. It’s hard to imagine the joke hardening these residents toward a type of patient he represents (delivery personnel?) in the future. The neighborhood’s staggering rates of crime and poverty might represent an external obstacle upsetting the residents, but residents are usually powerless to alter that type of structural factor.

I think the motivation for telling the joke was to integrate this terrible event and get through the shift. This teenager lost his life bringing these young doctors dinner. “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.

It’s important that the tip joke was told in an empty area with no family, friends, or other patients who could be harmed by overhearing. I’m usually a fan of sunshine tests and total disclosure, so I find the idea of secrecy as an ethical plus startling. But when a compassionate professional gets overwhelmed, gallows humor may be a psychic survival instinct, and that’s why it is not an abuse of patient trust when it’s done backstage and for the right reasons. Something that looks maleficent toward one patient may actually be an act of beneficence toward the patients who will come next. So yes—if the delivery boy were my son and I heard the joke, I would want to tear their eyes out. But if I was the person in the next ambulance, hurtling toward their emergency room after my car wreck, my heart attack, my rape, I’d be glad they made that joke. Because they needed to laugh before they could eat, and they needed to eat to be at their best when it was my turn.

David is a brilliant, compassionate physician who will serve patients his whole life, so I told him two things about the tip joke: I’m glad he did what he needed to do to treat every patient he’d see that night. And I’m glad it still bothers him. Because it’s good to carry that tension that tells you when you’re on thin ice. When a terrible joke is the only bridge between horror and necessity, gallows humor can be a show of respect for the work that lies ahead. So tell your jokes. Tell them somewhere I cannot hear. Then treat me well when we’re together.

For those interested, the article is free if you register with the website.  They have free limited access to certain articles.

Dignity Therapy: For The Dying, A Chance To Rewrite Life : NPR

Dignity Therapy: For The Dying, A Chance To Rewrite Life : NPR.

One of the important pieces of working with the dying is to give them or their families an opportunity to rethink and relay their lives to others.  We are afraid that we will not have a legacy, and as such, some of our fear of death could potentially be alleviated through reflection and story telling.  There is a formal methodology for this, which is called dignity therapy.  Unfortunately, for many, reflection comes too late because of other concerns getting in the way, such as the fear of telling the person the truth because if someone knows he is dying, the person will get very depressed.  Instead, dignity therapy is a means of working through the depression to find a place of meaning that will outlast one’s life. 

For several decades, psychiatrists who work with the dying have been trying to come up with new psychotherapies that can help people cope with the reality of their death. One of these therapies asks the dying to tell the story of their life.

This end-of-life treatment, called dignity therapy, was created by a man named Harvey Chochinov. When Chochinov was a young psychiatrist working with the dying, he had a powerful experience with one of the patients he was trying to counsel — a man with an inoperable brain tumor.

“One of the last times that I went into his room to meet with him, on his bedside table was a photograph of him when he had indeed been young and healthy and a bodybuilder, and it was this incredible juxtaposition of these two images,” says Chochinov.

So in the bed there’s his patient — this skeleton of a man — very pale and weak. On the bedside table, there’s this portrait of a glistening, muscled giant. And Chochinov says that sitting there, it was very clear to him that by placing this photograph in such a prominent position, the man was sending a message: This was how he needed to be seen.

As Chochinov continued his work with the dying, he confronted this again and again — this need people have to assert themselves in the face of death. And he started to wonder about it…

“When you face death, it’s like facing a wall, and it forces you to turn around and look at the life that you’ve lived,” says William Breitbart, a psychiatrist at Sloan-Kettering Cancer Center in New York. He’s been trying to develop new psychotherapies for the dying. He says that many people have the wrong idea about the dying process.

“The prevailing mythology is that you die the way you live, and you can’t change yourself in any way,” says Breitbart. “The fact is that the last few months of life — because of the awareness of death — create an urgency that facilitates growth and change.”

This, he says, is why something like dignity therapy can be good. Though there’s no evidence that it relieves depression or anxiety, he thinks it can help us change in the very last moment of our lives. After all, he says, we’ve all lived imperfect lives.

“All of us fail, and the process, the task of dying, is to relieve ourselves of this guilt, whether it’s forgiving yourself or asking others to forgive you,” says Breitbart. “Or to remember your life slightly differently. But that’s the task of dying.”

As for Frego, she says she’s developed a strange relationship to the document her mother put together. Since her mother’s death, Frego says she’s actually carried the document around with her. She has the story of her mother’s life, always at her side, knocking around in the bottom of her bag.

Are we fooling ourselves?

I came across another of Rev. Jacob’s posts on Huffington Post revolving around end-of-life issues.  She focuses on an article written a month ago which I already wrote about here.  She uses the story to elicit from her readers the question of how we would want our own death to look like, assuming we don’t suddenly drop dead.  She poses the following questions for us to contemplate:

What would you do were you in Dudley Clendinen’s situation? I am not asking you to judge what he has decided is right for him. I am asking you to consider what you would want were you to find yourself in Dudley’s situation. Would you want to die the way he describes his mother, cousin and his aunts did, “… all of whom would have died of natural causes years earlier if not for medical technology, well-meaning systems and loving, caring hands”? Or would you prefer what Dudley has decided? Or something else?

Also, thinking about the prospect of only having several months to live (although death could occur for any of us at any time — whether it be while walking down the street, eating a meal or sleeping), I wonder how many of us could do what Dudley is doing while he is dying — living one day at a time? For those of us who have not done a 12-step program, are we able to live today and focus only on this day? Can we appreciate what we have before us right now? “Consider the birds in the fields” (Matt 6:26) “Behold the lilies of the field” (Matt 6:28) — Can we just “be still, and know” (Ps 46:10) — Can we see the “goodness of the Lord in the land of the living?” (Ps 27:13)

What do you think that God expects of us as we live this life — and await our time to die? And, then, as Ecclesiastes reminds us, there is a time for everything … “A time to be born and a time to die …” (Eccl 3:1-2) We know that we will one day die. And, what do you think that God expects of us as we are dying?

From the standpoint of the questions she poses, I am left with one thought.  There are times we, the healthy, look on the ill or the elderly and say, “I don’t want to end up this way.  I would rather no aggressive interventions to prolong my life.”  Yet, I would venture that for many of us, as we age, we will think somewhat differently when faced with the closeness of our own mortality.  This is not to suggest a lack of belief in G-d or an afterlife, a subject unto themselves.  It is rather to say that a part of what makes us who we are will never want to disappear.  Our self is afraid of not existing.  That is why contemplating death is a difficult spiritual practice.  I think many are too quick to say I would rather not live if… On the flip side, for those who are suffering, realize that my critique is not about any of the trauma and challenge of chronic or life limiting illnesses.  I am merely saying that it is easy for the young and healthy to prefer death over a partial life when it is a hypothetical decision as opposed to something that is current in his/her life.