The incompatibility of the use of unclaimed bodies with ethical anatomical education in the United States

Teaching respect for body donors: A US medical student perspective

Recent controversies over the mismanagement of body donors in US medical schools have raised public concerns over the ethical treatment of bodies in "anatomical gift" programs. Despite widespread moral outrage at such cases, medical students may still make seemingly inconsequential mistakes or jokes that in fact constitute acts of disrespect. This may partially be attributed to the process of desensitization in working with human remains, and indicates a further need to inculcate into medical students the ethical responsibilities of working with body donors. Donation agreement statements that lack specific information about the respectful treatment of bodies in the anatomy laboratory may serve as an additional point of concern for potential donors seeking reassurance about the future treatment of their bodies. This viewpoint draws from the anecdotal experiences of medical students to portray two scenarios of medical students' disrespectful conduct toward body donors, and constructs an account of moral respect for human remains based on respect for posthumous autonomy and respect in attitude. It then provides suggestions for US medical schools to incorporate this ethical framework into their anatomy curricula to instill respectful dispositions in its students and facilitate a more robust informed consent process for potential donors who entrust their bodies to medical students.

Investigating the status of whole-body donation across the United States of America

Dissection of human body donors is a valuable part of anatomical education, research, and clinical training. In the United States, deceased human bodies are predominantly sourced through whole-body donation programs (BDPs) housed by academic institutions. Due to the lack of information regarding BDPs, the aim of this study was to gather information from US BDPs through a survey to better understand the donation process and standard operating procedures of these programs. In 2021, a Qualtrics survey was distributed to 125 BDPs and yielded responses from 72 program leaders. Collectively, these programs received more than 26,000 whole-body donations annually. Findings show that 70% typically receive enough donations to fit the needs of their institutions, 17% receive a surplus of donations, and 13% receive too few donations. Sixty-eight percent of programs permit next of kin body donation regularly or in times of need, and 44% allow next of kin to make changes to a donor's donation form after death. On average, over 85% of the registered donor population is composed of white individuals, and only 6 institutions have methods in place to promote diversity among their donor population. Overall, there is considerable variability in the operation of BDPs across the United States. These findings can be used to make recommendations about donor enrollment and program operations to ultimately improve the donation process. Future research needs to investigate the opinions and preferences of body donors along with their next of kin on the body donation process and associated policies.

Unclaimed Bodies in Anatomical Education: Medical Student Attitudes at One U.S. Medical Institution

PHENOMENON

Dissection of cadavers is a common practice in anatomical education. To meet demand for cadavers, some medical institutions facilitate dissection of individuals who did not provide consent during their life. This includes the bodies of individuals who passed away with either no living kin or no kin able to claim and bury their body. Recent literature demonstrates widespread discomfort with this practice among anatomy course directors at U.S. institutions, bringing into question continuation of this practice. However, attitudes among medical students must similarly be assessed as they represent key stakeholders in the dissection process. The purpose of this study was to assess prevailing attitudes among a sample of medical students at one U.S. medical institution regarding the dissection of unclaimed bodies and identify emerging themes in ethical viewpoints.

APPROACH

Two-hundred-twelve students (35% response rate) at one U.S. medical institution completed an anonymous online survey. Students came from different class cohorts at various stages of their training. Survey items were developed to capture students' academic and emotional experience with anatomical dissection and to identify emerging themes in attitudes.

FINDINGS

Students reported high regard for cadaveric dissection in general with 170 (80%) respondents endorsing it as critical to anatomical education. Regarding dissection of unclaimed bodies, 30% of students found the practice ethical while 47% of students found the practice unethical. Multivariate analysis found that ethical view was directly associated with comfort level (OR= 156.16; 95% CI: 34.04, 716.40). Most students expressed comfort dissecting self-donated bodies (n = 206, 97%), while fewer students expressed comfort dissecting unclaimed bodies (n = 66, 31.1%). This latter finding significantly correlated with gender (t = 3.361. p < 0.05), class cohort (F = 3.576, p < 0.01), but not with religious affiliation or age. Thematic analysis revealed the following themes in student responses: (1) invoking ethical paradigms to either justify or condemn the practice, (2) subjective experiences, and (3) withholding judgment of the practice.

INSIGHTS

Many students expressed negative attitudes toward the dissection of unclaimed bodies, with some citing issues of social vulnerability, justice, and autonomy. These findings indicate that many students' ethical code may conflict with institutional policies which permit this practice. Medical school represents a critical time in the professional development of trainees, and development practices which align with the moral code of local institutions and stakeholders is crucial.

Anatomists' uses of human skeletons: Ethical issues associated with the India bone trade and anonymized archival collections

Concerns have recently been expressed about the continuing availability of human bones from India, obtained originally for educational purposes but lacking the requisite informed consent that would be expected today. More generally, a broader claim is being made, namely, that the practice of using any unconsented bones in educational settings is unethical and should cease. These calls, in turn, raise broader issues regarding the availability of anonymous archival collections in anatomy museums. Although this debate centers on undergraduate anatomy teaching, much anthropological research utilizes human remains of past populations for which there can have been no consent. A suggested alternative for undergraduate teaching is the use of 3D images of human bones, rather than the bones themselves. In addressing these issues, the background to the India bone trade is assessed, and the year 1985 is pinpointed as having significant ethical weight. The cultural and ethical interests inherent in studying archival anonymous skeletal material are weighed against indiscriminate reburial. Although any use of unconsented material represents ethical compromise, account should be taken of changing ethical expectations with time. It is concluded that: there is no justification for repatriation or disposal of all bones for which specific informed consent has not been obtained; continued use of anonymous archival human bones in a professional setting is acceptable, even in the absence of informed consent, with the proviso that there are no culturally relevant groups seeking repatriation; the continued existence of bones in long-standing private collections cannot be justified since it amounts to long-term storage with no identified goals; the notion that 3D images are an ethically superior alternative to actual human bones is unsustainable, since there is an intimate connection between the bones and the 3D images.

Graphic medicine meets human anatomy: The potential role of comics in raising whole body donation awareness in Italy and beyond. A pilot study

Cadaver dissection has always played a fundamental role in medical education. However, especially in Italy, the topic of body donation has remained partially unknown for years. The current study analyses graphic medicine as a new possible communication tool, evaluating and reflecting, with second-year students enrolled in the International School of Medicine and Surgery at the University of Bologna, about its potentialities for body donation awareness-raising in both the scientific community and the general population. For the first time in an Italian University, two graphic medicine workshops were organized focusing on human anatomy and body donation. Seminars were positively evaluated by students using a four items Likert-scale question: mean 3.54 (± SD 0.73) for the Likert question about the experiences of the workshops; 3.88 (± 0.33) for the Likert question regarding the use of graphic medicine in body donation awareness campaigns among the general population; 3.59 (± 0.65) for the Likert question regarding the use of graphic medicine in body donation awareness campaigns among the scientific community. Furthermore, the open-ended questions included in the anonymous questionnaire were analyzed using the constructivist grounded qualitative analysis, whence various themes emerged. Finally, five graphic medicine projects about body donation were created by students, proving their interest in testing this method to promote body donation, focusing the attention on different communicative aspects. Considering the results of this pilot study, the co-creative collaborative use of graphic medicine could be evaluated as an additional strategy to increase body donation awareness-raising in Italy and beyond, especially in the non-experts' community.

The ethical use of digital technology in teaching anatomy: A southern African perspective

BACKGROUND

The use of 21st Century technology in anatomy teaching and the recent crisis caused by the Coronavirus pandemic has stimulated anatomists to ponder the ethics surrounding the utilisation of digital images from human bodies of known and unknown provenance in teaching.

AIM

This novel study explores the awareness of southern African anatomy educators regarding the provenance and ethical use of human material in digital resources for E-learning purposes.

MATERIALS AND METHOD

Anatomy educators (both members and non-members of the Anatomical Society of Southern Africa including postgraduate students in anatomy) located in 15 health sciences facilities in southern Africa were asked to participate in the survey which consisted of an anonymous, cross-sectional, questionnaire conducted on an online research data system, REDCap.

RESULTS

While 52% of respondents used E-learning resources sourced from their own departments for teaching, only 58% of these had knowledge of the provenance of the human material used. Of the 72% of respondents using images from external E-learning resources, 64% did not know the provenance of the human material in these resources. Some southern African anatomists considered anonymity as equivalent to informed consent. Regarding the acceptability of unclaimed bodies for online images, 37% of respondents were against the use of these bodies, while 20% indicated that it was acceptable. Personal internal moral conflict was acknowledged regarding the use of material from unclaimed bodies, particularly during crises such as the Coronavirus pandemic when digital resources were limited.

DISCUSSION AND CONCLUSIONS

Factors such as lack of awareness of provenance, the law in South Africa and using anonymity for consent, influence the ethical behaviour of southern African anatomists. Clear guiding principles would be of value for anatomists globally with respect to consent to the taking and distribution of images, and transparency on the source of the digital images provided in digital texts and online platforms. The establishment of both an oversight and ethics committee at institutions where digital imaging will be used is recommended.

Books, bones and bodies: The relevance of the history of anatomy in Nazi Germany for medical education today

The history of anatomy in Nazi Germany highlights the consequences to humanity when the destructive potentials immanent to all science and medicine are enabled by an anti-democratic, totalitarian regime. Anatomy presents an example of ethical transgressions by scientists and health care professionals that were amplified in the criminal political climate of the Nazi regime. This can happen anywhere, as science is never apolitical. This article gives a short account of anatomy in Nazi Germany, which is followed by an outline of the tangible and intangible legacies from this history, to then discuss implications for anatomy education today. While Jewish and politically dissident anatomists were forced out of their positions and country by the Nazi regime, the majority of the remaining anatomists joined the Nazi party and used bodies of Nazi victims for education and research. Some anatomists even performed deadly human experiments. Patterns and legacies that emerge from this history can be traced into the present and concern research ethics in general and anatomical body procurement specifically. They shed light on current practices and controversies in the anatomical sciences, including anthropology. It will be argued here that the history of anatomy in Nazi Germany can inform current anatomy education in a concept of anatomy as the first "clinical discipline." By integrating insights from the history of anatomy into the learning process, anatomy education can model an approach to medicine that includes a full appreciation of the shared humanity of medical practitioners and patients.

Anatomy as a Model Environment for Acquiring Professional Competencies in Medicine: Experiences at Harvard Medical School

Anatomy education provides students with opportunities to learn structure and function of the human body, to acquire professional competencies such as teamwork, interpersonal skills, self-awareness, and to reflect on and practice medical ethics. The fulfillment of this wide potential can present challenges in courses that are part of an integrated curriculum and shorter than traditional courses. This new reality, together with students' increasing concern about the stresses within medical education, led to efforts at Harvard Medical School to implement practical steps toward an optimal learning environment in anatomy. These were based on core elements of ethical anatomy education and principles of trauma-informed care. Anatomy is conceptualized here as the "first clinical discipline," with relational interactions between anatomical educators, medical students, and body donors/patients. Essential prerequisites for the implementation of this work were support by the medical school leadership, open partnership between engaged students and faculty, faculty coordination, and peer-teaching. Specific interventions included pre-course faculty development on course philosophy and invitations to students to share their thoughts on anatomy. Student responses were integrated in course introductions, combined with a pre-dissection laboratory visit, an introductory guide, and a module on the history and ethics of anatomy. During the course, team-building activities were scheduled, and self-reflection encouraged, for example, through written exercises, and elective life-body drawing. Students' responses to the interventions were overall positive, but need further evaluation. This first attempt of a systematic implementation of an optimal learning environment in anatomy led to the identification of areas in need of adjustment.

From undergraduate to postgraduate uses of the dead human body: consequential ethical shift

The dependence of surgical training programmes on the supply of bodies by for-profit organisations places them at serious ethical risk. These risks, with their commodification of the bodies used in the programme, are outlined. It is concluded that this is not a satisfactory model for the trainees' subsequent interaction with living patients and that a code of practice is required.

Of Discomfort and Disagreement: Unclaimed Bodies in Anatomy Laboratories at United States Medical Schools

Use of unclaimed bodies for anatomy teaching in undergraduate medical education continues, but is ethically controversial. The purposes of this study were to estimate the proportion of United States (US) medical schools using unclaimed bodies in first-year anatomy laboratories, to determine whether schools inform students of this use, and to explore anatomy course leaders' attitudes toward unclaimed body use. Anatomy course leaders from 146 US medical schools that had independent preclinical programs including anatomy were surveyed. Survey results were analyzed with descriptive statistics and statistical tests of association. Free text responses were analyzed using a thematic editing style of qualitative content analysis. Of 89 responses (response rate, 61.0%), 11 schools (12.4%) reported possible use of unclaimed bodies. Course leaders from these schools reported greater comfort with using unclaimed bodies compared to leaders from other schools (P < 0.01). Although most course leaders (49/76, or 64.5%) believed it was important or very important to inform students about use of unclaimed bodies, respondents from schools where unclaimed bodies could be used were more neutral (P < 0.01). Qualitative findings revealed deep disagreement and contradictory views about how unclaimed body use relates to ethical principles of respect for persons and justice. Continued use of unclaimed bodies, varying levels of comfort with their use, and disagreement about the practices' underlying morality suggest a need for greater ethical reflection about the permissibility of unclaimed body use in clinical anatomy and for educational interventions that teach students about its history, ethics, and contemporary practice.

BODIES R US: Ethical Views on the Commercialization of the Dead in Medical Education and Research

With the ongoing and expanding use of willed bodies in medical education and research, there has been a concomitant rise in the need for willed bodies and an increase in the means of supplying these bodies. A relatively recent development to enlarge this supply has been the growth of for- profit willed body companies ("body brokers") in the United States. These companies advertise for donors, cover all cremation and other fees for the donor, distribute the bodies or body parts nationally and internationally, and charge their users for access to the body or body parts. In doing so, they generate substantial profits. This review examines the historical development of willed body programs, the legal and economic aspects of willed body programs, and then provides an ethical framework for the use of willed bodies. The ethical principles described include detailed informed consent from the donors, comprehensive and transparent information about the process from the body donation organizations, and societal input on the proper and legal handling of willed bodies. Based on the ethical principles outlined, it is recommended that there be no commercialization or commodification of willed bodies, and that programs that use willed bodies should not generate profit.

Bodies for Anatomy Education in Medical Schools: An Overview of the Sources of Cadavers Worldwide

The International Federation of Associations of Anatomists (IFAA) recommended in 2012 that only donated bodies be used for anatomy teaching and research. However, in many countries around the world, anatomists still depend on bodies that do not stem from voluntary donations by the deceased but, rather, are "unclaimed." A broad search of the literature was conducted to produce a baseline overview of the sources of cadavers used for anatomy teaching in undergraduate medical curricula on a global scale. Information from the literature search was supplemented with data from a 2016-2017 survey of selected senior local anatomists. Of 165 countries with medical schools, information was gathered for 71. In 22 (32%) of the 68 countries that use cadavers for anatomy teaching, body donation is the exclusive source of bodies. However, in most other countries, unclaimed bodies remain the main (n = 18; 26%) or exclusive (n = 21; 31%) source. Some countries import cadavers from abroad, mainly from the United States or India. In one country, bodies of executed persons are given to anatomy departments. The heterogeneous geographical distribution of body sources cannot easily be accounted for, but religion, culture, and folk beliefs about what should happen to bodies after death seem to play a role. Implementation of the IFAA recommendations still has a long way to go, but it is encouraging that functioning body donation programs exist on all continents and that there are examples of recent rises in donations and of anatomists initiating new donation programs.

Does Confucianism allow for body donation?

Confucianism has been widely perceived as a major moral and cultural obstacle to the donation of bodies for anatomical purposes. The rationale for this is the Confucian stress on xiao (filial piety), whereby individuals' bodies are to be intact at death. In the view of many, the result is a prohibition on the donation of bodies to anatomy departments for the purpose of dissection. The role of dissection throughout the development of anatomy within a Confucian context is traced, and in contemporary China the establishment of donation programs and the appearance of memorial monuments is noted. In reassessing Confucian attitudes, the stress laid on a particular interpretation of filial piety is questioned, and an attempt is made to balance this with the Confucian emphasis on a moral duty to those outside one's immediate family. The authors argue that the fundamental Confucian norm ren (humaneness or benevolence) allows for body donation as people have a moral duty to help others. Moreover, the other central Confucian value, li (rites), offers important insights on how body donation should be performed as a communal activity, particularly the necessity of developing ethically and culturally appropriate rituals for body donation. In seeking to learn from this from a Western perspective, it is contended that in all societies the voluntary donation of bodies is a deeply human activity that is to reflect the characteristics of the community within which it takes place. This is in large part because it has educational and personal repercussions for students. Anat Sci Educ 11: 525-531. © 2018 American Association of Anatomists.

Anonymous body or first patient? A status report and needs assessment regarding the personalization of donors in dissection courses in German, Austrian, and Swiss Medical Schools

Many Anglo-American universities have undertaken a paradigm shift in how the dissection of human material is approached, such that students are encouraged to learn about the lives of body donors, and to respectfully "personalize" them as human beings, rather than treating the specimens as anonymous cadavers. For the purposes of this study, this provision of limited personal information regarding the life of a body donor will be referred to as "personalization" of body donors. At this time, it is unknown whether this paradigm shift in the personalization of body donors can be translated into the German-speaking world. A shift from donor anonymity to donor personalization could strengthen students' perception of the donor as a "first patient," and thereby reinforce their ability to empathize with their future patients. Therefore, this study aimed to collect data about the current status of donation practices at German-speaking anatomy departments (n = 44) and to describe the opinions of anatomy departments, students (n = 366), and donors (n = 227) about possible donor personalization in medical education. Anatomy departments in Germany, Austria, and Switzerland were invited to participate in an online questionnaire. One-tenth of registered donors at Ulm University were randomly selected and received a questionnaire (20 items, yes-no questions) by mail. Students at the University of Ulm were also surveyed at the end of the dissection course (31 items, six-point Likert-scale). The majority of students were interested in receiving additional information about their donors (78.1%). A majority of donors also supported the anonymous disclosure of information about their medical history (92.5%). However, this information is only available in about 28% of the departments surveyed and is communicated to the students only irregularly. Overall, 78% of anatomy departments were not in favor of undertaking donor personalization. The results appear to reflect traditional attitudes among anatomy departments. However, since students clearly preferred receiving additional donor information, and most donors expressed a willingness to provide this information, one could argue that a change in attitudes is necessary. To do so, official recommendations for a limited, anonymous personalization of donated cadaveric specimens might be necessary. Anat Sci Educ 11: 282-293. © 2017 American Association of Anatomists.

Current status of cadaver sources in Turkey and a wake-up call for Turkish anatomists

Persisting difficulties in body procurement in Turkey led to the acquisition of donated, unclaimed, autopsied, and imported bodies regulated under current legislature. Yet, no study had investigated the extent of the on-going cadaver problem. This study was aimed to outline cadaver sources in anatomy departments and their effectiveness by means of an online survey. Additionally, official websites of each department were investigated regarding any information on body donation. Unclaimed cadavers (84.8%) were the major source for anatomy departments, followed by donated (50%) and imported cadavers (39.1%). Foundation-based medical faculties were more likely to import cadavers (P = 0.008). There was a moderate increase (r_s  = 0.567; P = 0.018) in donation registrations to our department after 2000. The departments in cities with significantly higher City-Based Gross Domestic Product measures (US$9,900 vs. US$16,772, P = 0.041), frequencies for mid- or high-school graduates (30.4% vs. 31.3%, P = 0.041), and frequencies for under- or post-graduates (13.1% vs. 15.8%, P = 0.24) had managed to use donated cadavers. Anatomy departments' major reasons for using unclaimed cadavers were education (45.9%), unclaimed cadavers being the only source (24.3%), and receiving inadequate donations (21.6%). Nine out of seventy-four departments (12.2%) provided information regarding body donation on their websites. Body procurement remains as a serious problem in Turkey and it is apparent that current legislature does not provide a sufficient cadaver inflow. Similarly, anatomy departments' effectiveness in public awareness of body donation and support in the National Body Donation Campaign seems questionable. Anat Sci Educ 11: 155-165. © 2017 American Association of Anatomists.