A Bioethos for Bodies: Respecting a Priceless Resource

Historical trends and current experiences of anatomical body donation in two Zimbabwean medical schools

BACKGROUND

Body donation is integral to anatomy education, but procurement can be ethically fraught. While voluntary donation is preferred, the use of unclaimed bodies, although considered unethical, is a primary means for body procurement in some countries. This mixed methods study examined historical trends and anatomy technical staff perspectives on body donation in two Zimbabwean medical schools.

METHODOLOGY AND MAIN FINDINGS

In Phase 1, 194 cadaver paper records from January 1984 to January 2021 were reviewed. Unclaimed bodies accounted for 67% while 33% (all white Zimbabweans) were voluntarily donated. Most cadavers were black Africans (62.4%) followed by white Zimbabweans (34.0%). Race was not indicated in seven (3.6%) records. In Phase 2, semi-structured interviews were conducted with seven technicians responsible for sourcing cadavers at the two institutions. Data were thematically analysed resulting in the development of eight themes, arranged into three domains. Cadaver procurement themes related to (1) cadaver source, (2) adherence to procurement guidelines, (3) screening for suitability, and (4) cultural and religious beliefs. Cadaver embalmment focused on (5) embalming practices, and (6) hospital mortuary-based embalming. Finally, (7) disposal processes and (8) resource constraints were found to influence cadaver disposal practices.

CONCLUSIONS

Contrary to best practice, there is continued reliance on the use of unclaimed bodies to support anatomy education in the two Zimbabwean medical schools. Improving the ethical sourcing of bodies requires increased efforts to educate all Zimbabweans, especially the black majority, about the role and importance of voluntary body donation in medical education. Additionally, well-structured, and well-resourced body donation programs could enhance ethical procurement.

Giving a voice to our silent teachers: Whole body donation from the donor perspective at one donation program in the United States

Human body donors play a crucial role in anatomical education, research, and clinical skills training, and those interested in anatomical donation may bequeath their bodies to body donation programs (BDPs). The purpose of this study was to evaluate the perspective of body donors on the donation process in order to make recommendations for improvement that align with donor values. A survey was administered via email to 2145 individuals that had enrolled in The Ohio State University's BDP and yielded a 40% response rate. Results showed that a majority of registered donors do not place high importance on detailed consent options during the enrollment process, but do value BDP oversight, such as through the use of an oversight committee to supervise the program. Only 9.1% of donors felt that their loved ones should be permitted to make changes to their consent forms after they have passed. Although 96.2% of participants would allow photos/videos to be taken of their donated bodies, females were significantly less likely to consent to this than males (p = 0.001), as well as less likely to allow their donations to be utilized for anatomy outreach (p = 0.023). Racial minorities were significantly less trusting of the university to treat their donation with dignity and respect compared to White registrants (p = 0.034). Suggestions for improving BDP protocols include the implementation of an annual newsletter for registrants, improving methods to spread awareness about donation, increasing transparency during the consent process, and creating resources for donors' families.

Honoring human body donors: Five core themes to consider regarding ethical treatment and memorialization

Dissection of human body donors is a common component of anatomy curricula, as it provides opportunities for tactile and intellectual engagement unmatched otherwise. Additionally, interaction with human body donors contributes to the "hidden curriculum" of allowing students to begin to ethically practice patient care with empathy, respect, and compassion. With this, there have been various proposed guidelines for the ethical treatment of human body donors, with most focusing on student reflections and a final ceremony for honoring the donors, but there are numerous other ways throughout the course to incorporate ethical values and to guide students to consider the humanity of the donor. This article proposes that institutions consider the incorporation of five easily implemented formalized ethical themes for working with human body donations into daily practices: (1) reflect the donor as possessing human dignity, (2) recognize the donor's role of the "First Patient" or "Silent Teacher," (3) honor the gift of human body donation, (4) recognize the decedent's family, and (5) consider inclusivity in memorialization practices. Multiple recommendations for integrating these five themes throughout the course are provided. The incorporation of these five core themes can assist in alleviating the psychological stress that some students struggle with in dissection courses, foster the feelings and attributes that comprise the hidden curriculum and are the desired characteristics of a caring medical provider, and discourage misuse and mistreatment of donors.

Inspired anatomy education: Might God be relevant?

Anatomy education is essential for developing healthcare professionals, and discussion continues about factors that impact and improve the anatomy learning environment. Neglected in this discussion is a consideration of the diverse religious assumptions and beliefs that college students bring to anatomy learning. Surveys of religion among United States college students indicate that many identify as religious and Christian. This viewpoint commentary summarizes main elements of Christian theology and anthropology, discusses the holistic and positive view of the body presented in Christian scripture, and outlines how these Christian beliefs inform and impact student preparation for anatomy education and human body dissection, address ethical issues in body donation, and support professionalism for future career practice.

Ethical concerns surrounding artificial intelligence in anatomy education: Should AI human body simulations replace donors in the dissection room?

The potential effects of artificial intelligence (AI) on the teaching of anatomy are unclear. We explore the hypothetical situation of human body donors being replaced by AI human body simulations and reflect on two separate ethical concerns: first, whether it is permissible to replace donors with AI human body simulations in the dissection room when the consequences of doing so are unclear, and second, the overarching ethical significance of AI use in anatomy education. To do this, we highlight the key benefits of student exposure to the dissection room and body donors, including nontechnical, discipline-independent skills, awareness and interaction with applied bioethics, and professional identity formation. We suggest that the uniqueness of the dissection room experience and the importance of the key benefits accompanying this exposure outweigh the potential and so far unknown benefits of AI technology in this space. Further, the lack of engagement with bioethical principles that are intimately intertwined with the dissection room experience may have repercussions for future healthcare professional development. We argue that interaction with body donors must be protected and maintained and not replaced with AI human body donor simulations. Any move away from this foundation of anatomy education requires scrutiny. In light of the possible adoption of AI technologies into anatomy teaching, it is necessary that medical educators reflect on the dictum that the practice of healthcare, and anatomy, is a uniquely human endeavor.

Ethical and Practical Considerations Associated with Companion Animal Euthanasia

The reality that euthanasia in veterinary practice can end animal suffering but can also be used in circumstances that do not serve an animal's interest, can be a benefit for animals, and a burden for veterinary professionals, respectively. This essay addresses ethical and practical concerns associated with companion animal euthanasia, including defining euthanasia, why and when euthanasia should be performed, applying euthanasia in practice, contemporary methods, aftercare of deceased animals, and the consequences of euthanasia and dysthanasia for animals, animal owners, and veterinary professionals. We contend that an intention-based definition of euthanasia should be strictly applied in veterinary practice and that practitioners view euthanasia decisions as requests that can (and in some cases should) be declined, rather than as mandates.

The Italian law on body donation: A position paper of the Italian College of Anatomists

In Italy, recent legislation (Law No. 10/2020) has tuned regulations concerning the donation of one's postmortem body and tissues for study, training, and scientific research purposes. This study discusses several specific issues to optimise the applicability and effectiveness of such an important, novel regulatory setting. Critical issues arise concerning the learners, the type of training and teaching activities that can be planned, the position of academic anatomy institutes, the role of family members in the donation process, the time frame of the donation process, the eligibility of partial donation, or the simultaneous donation of organs and tissues to patients awaiting transplantation. In particular, a universal time limit for donations (i.e., one year) makes it impossible to plan the long-term use of specific body parts, which could be effectively preserved for the advanced teaching and training of medical students and surgeons. The abovementioned conditions lead to the limited use of corpses, thus resulting in the inefficiency of the whole system of body donation. Overall, the donors' scope for the donation of their body could be best honoured by a more flexible and tuneable approach that can be used on a case-by-case basis. Furthermore, it is deemed necessary to closely monitor the events scheduled for corpses in public nonacademic institutions or private enterprises. This paper presents useful insights from Italian anatomists with the hope of providing inspiration for drafting the regulations. In conclusion, this paper focuses on the critical issues derived from the recently introduced Italian law on the donation and use of the body after death and provides suggestions to lawmakers for future implementations.

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.

Regarding the Dead: A Model for Anatomical Gifting Outside the Traditional Medical School Setting

In 2017, Elon University became one of very few universities in the United States without a medical school to have an in-house Anatomical Gift Program (AGP). The program accepts first-person-consenting individuals only and within 2.5 years has become self-sufficient, supporting anatomy curricular needs of its physical therapy, physician assistant, and undergraduate biology and anthropology programs (n = 21 donors annually). This paper describes the timeline, costs, and benefits of developing an in-house AGP at a university without a medical school. Policy development, public outreach, equipment needs, and cost benefits are discussed. Within 2.5 years of program opening, the AGP Director delivered 161 educational outreach presentations at 86 different venues across the state providing information on anatomical gifting. The program registered 320 individuals (60% female, 40% male) and enrolled 41 deceased donors (69% female, 31% male; average age of 74.6 at time of registration and 74.8 at donation). During the first seven months of the program, donor preparation costs (with outsourcing for transport/donor preparation/document filing/serology testing/cremation) averaged US$ 2,100 per donor. Over the past 23 months, donor preparation has been completed on site, lowering the cost per donor to US$ 1,260. Other costs include personnel salaries, legal fees, and outfitting of the anatomy laboratory and preparatory room. Program benefits include support of anatomy education on campus, assurance that all donors have given first-person consent, and faculty/student access to donor-determined health, social, and occupational information. Faculty, staff, and students contribute to the daily operations of the AGP.

The whole body donation program at the university of Bologna: A report based on the experience of one of the oldest university in Western world

Human body dissection is fundamental in medical education, as it allows future physicians to learn about the body's morphology in three dimensions, to recognize anatomical variations and to develop and increase the essential qualities of respect, compassion and empathy for patients. It is equally important in clinical training as it allows surgeons to improve their manual dexterity and practical skills and to test innovative surgical techniques and devices. In Italy prior to 2020, body acquisition and use for study and research purposes were regulated by a generic set of old directives and national decrees which dealt only marginally with these issues. However, in 2013, a whole body donation program was officially set up at the Institute of Human Anatomy of the University of Bologna. Completely free and voluntary informed consent has always been regarded as a core prerequisite and, since its inception, the program exclusively accepted bequeathed bodies. On February 10, 2020, a specific law governing the disposition of post mortem human body and tissues for study, training and scientific research purposes was definitively enacted. The present work traces the University of Bologna's experience leading to the whole body donation program and the brand new dissecting room. It describes the program of Bologna as an example of "good practice" in body donation, aimed at ensuring education and clinical training by means of both traditional gross anatomy and innovative technology. Moreover, it analyzes the results achieved in terms of increased donor enrollment and improved teaching/training quality and the strengths of this program in light of the provisions enshrined in the new law.

A Good Death - Can the Concept Be Applied to Anatomy?

The importance of patient-centered decisions is embedded throughout clinical practice. The principle that the patient is at the center of all decisions has helped form the contemporary approach to death and dying. The concept of a "good death" will naturally mean different things to different individuals, but is based on the foundation of being pain free, comfortable, and able to make informed decisions. Potential donors are faced with many personal, ethical, and often spiritual considerations when they come to think about their wishes after death. One consideration is that of a "good death." This article explores how the concept of a "good death" may be applied to anatomy. Where first-person consent is in place, the motivating factors frequently include the wish for others to learn from the donation, and this notion may form part of the "good death" for the donor. Such motivations may impact positively on how students feel about dissecting and may provide comfort, assuaging feelings of discomfort, and allowing students to focus on anatomical learning. For donors where second-person consent is in place, the concept of a "good death" must depend on whether the individual wanted to donate their body in the first instance. The notion of a "bad death" may also be considered with body donation where no consent for donation is in place. This article proposes that there is ultimately a place for the concept that a "good death" may involve an individual donating their body to medical education.

The practice of ethics in the context of human dissection: Setting standards for future physicians

It is a much desirable skill among physicians that clinical practice should be guided by ethical norms. The dissection room experience provides an opportunity for nurturing the principles of ethical practice among medical students early in the curriculum. When the exercise of human dissection is followed within the boundaries of ethics it effectively props an ideal example for the young minds to emulate in the future. Hence in every stage of dissection room activity precious human body needs to be handled in an ethical manner so as to set a standard for the students. The present review is an attempt to collate the recommendations documented by researchers as per ethical guidelines in the context of human dissection. The review highlights on the ethical norms which needs to be adhered to while receiving the human body of a donor and during preservation of the same. It reflects on ideal ethical behaviour in the dissection room during the act of dissection and finally emphasize on the respectful disposal of the human remains in an ethical manner. The intended purpose of this article is to support uniform adoption of the recommendations for ethical handling of human bodies used in anatomical dissection.

Social Media Guidelines for Anatomists

Social Media has changed the way that individuals interact with each other - it has brought considerable benefits, yet also some challenges. Social media in anatomy has enabled anatomists all over the world to engage, interact and form new collaborations that otherwise would not have been possible. In a relatively small discipline where individuals may be working as the only anatomist in an institution, having such a virtual community can be important. Social media is also being used as a means for anatomists to communicate with the current generation of students as well as members of the public. Posting appropriate content is one of the challenges raised by social media use in anatomy. Human cadaveric material is frequently shared on social media and there is divided opinion among anatomists on whether or not such content is appropriate. This article explores the uses and challenges of social media use in the field of anatomy and outlines guidelines on how social media can be used by anatomists globally, while maintaining professional and ethical standards. Creating global guidelines has shown to be difficult due to the differences in international law for the use of human tissue and also the irregularities in acquiring informed consent for capturing and sharing cadaveric images. These nuances may explain why cadaveric images are frequently shared on social media. This article proposes that as standard practice, anatomists obtain informed consent from donors before sharing images of cadaveric material on social media and ensure posts include a statement stating the same.

Body donation in Italy: Lights and shadows of law No. 10/2020

INTRODUCTION

Recently, law No. 10 of February 10, 2020, entitled "Rules regarding the disposition of one's body and post-mortem tissues for study, training, and scientific research purposes" was introduced in Italy. Although its provisions respond to a constructive subject, some practical issues are evident in the approved text.

MATERIALS AND METHODS

A systematic review of the literature was performed by searching online medical and juridical databases to identify publications and Italian law provisions related to body donation programs.

RESULTS

The updated regulatory framework was outlined and compared to that in force previously, and the following features are discussed: (a) matter of law; (b) donors' information and consent; (c) reference centers and funding, and (d) procedural regulatory details. Several critical issues were detected in the approved wording with respect to teaching/training recipients, the role of university anatomy institutes, family members' exclusion from participating in the donation process in any capacity, the duration of donation, the management of corpses, partial donations, and the compatibility with organ donation. Suggestions are provided to overcome certain operational limitations in implementing the regulation, which is still being drafted to date.

CONCLUSIONS

This article shares with the international scientific community the principles and controversies underlying a regulatory innovation introduced in Italy to allow legislative amendments to inadequate provisions of body donation, as well as draw the attention of the entire anatomic community to critical issues if other countries undertake the same legislative reform.

Knowledge, attitude and willingness of different ethnicities to participate in cadaver donation programs

Knowledge, attitude and willingness of ethnic minorities in China towards cadaver donation programs were assessed. Questionnaire and interviews were conducted to investigate Yi, Bai, Hani, Dai and Han ethnicities. Educational level and per capita income of ethnic minorities were lesser than those of Han ethnicity (p<0.01). Agriculture was the primary occupation and proportions of technical personnel and public officials was lesser among ethnic minorities (p<0.01). Surveyed ethnic minorities universally practice religious traditions, Bai and Dai ethnicities practice Buddhist beliefs also (p<0.01). Knowledge of Yi, Bai, Hani and Dai ethnic respondents was lesser than those of Han ethnicity (p<0.01). Over 83.8% of Yi, Bai, Hani and Dai ethnicity residents were unwilling to register for body donation programs with receiving a driver's license (p<0.01). Less than 46.9% of ethnic minorities supported use of honorary certificates (p<0.01). Ethnic minorities were supportive of financial compensation for body donations and denied that financial compensation led to the commercialization of cadaver donation (p<0.01, p<0.01). Willingness of ethnic minorities to participate in cadaver donation programs was primarily related to religious beliefs (p<0.01), economic status (p<0.01). Knowledge, attitude and willingness of ethnic minorities to participate in cadaver donation programs were markedly different from those of Han ethnicity, and the religious belief and economic status played a decisive role. To increase participation, programs based on respecting religious belief should be developed to support improvements in economy, education, medical care and social security system.

Ethical Rationales and Guidelines for the Continued Use of Archival Collections of Embryonic and Fetal Specimens

Benefits from the use of cadavers in anatomical education are well described. Historically, human embryos and fetal cadavers were used in anatomy education to understand development and congenital malformations. Recently, three-dimensional printed models produced from archival fetal specimens, and online repositories of images from archival collections of embryos and fetuses, have been used as an educational tool in human development courses. Given that the archival specimens were likely obtained prior to the era of informed consent, this raises questions about their appropriate and ethical use. Because some institutions in the United States retain archival collections of embryonic and fetal specimens that were once used as educational tools, their existence and utility require frequent reexamination against contemporary ethical frameworks to guide appropriate use or utilization. Four ethical rationales for uses of these collections are examined, including destruction, indefinite storage, use in research, and use in health professions education. Guidelines for the use of archival collections of human embryos and fetuses are presented. Indefinite storage and use in health professions education are supported, while use in research is also permitted, however, such use is limited and dependent on circumstance and purpose. The development of current digital repositories and three-dimensionally printed models based on archival collections that were collected without informed consent, or those promoting commercial opportunity, are not supported. New embryonic and fetal donations obtained with informed consent should include reference to potential uses with new technology and virtual, genetic, or imaging applications.

How does Donor Dissection Influence Medical Students' Perceptions of Ethics? A Cross-Sectional and Longitudinal Qualitative Study

The contribution of donor dissection to modern anatomy pedagogy remains debated. While short-term anatomy knowledge gains from dissection are questionable, studies suggest that donor dissection may have other impacts on students including influencing medical students' professional development, though evidence for such is limited. To improve the understanding of how anatomy education influences medical student professional development, the cross-sectional and longitudinal impacts of donor dissection on medical students' perceptions of ethics were explored. A cross-sectional and longitudinal qualitative study was undertaken at an Australian university where student responses to online discussion forums and in-person interviews were analyzed. Data were collected across the 1.5 years that undergraduate medical students received anatomy instruction (three semesters during first and second years). A total of 207 students participated in the online discussion forums, yielding 51,024 words; 24 students participated in at least 1 of 11 interviews, yielding over 11 hours of interview data. Framework analysis identified five themes related to ethics in an anatomical education context: (1) Dignity, (2) Beneficence, (3) Consent, (4) Justification for versus the necessity of dissection, and (5) Dichotomy of objectification and personification. The dominant themes of students' ethical perceptions changed with time, with a shift from focusing on donors as people, toward the utility of donors in anatomy education. Additionally, themes varied by student demographics including gender, ancestry, and religiosity. Together this study suggests a strong impact of donor dissection on priming students' focus on medical ethics and provides further advocacy for formal and purposeful integration of medical ethics with anatomy education.

Confucian Ethics on the Commercial Use of Human Bodies and Body Parts: Yi (Righteousness) or/and Li (Profit)?

In China as elsewhere in the world, human bodies and body parts have long been used for a wide range of medical and non-medical purposes. In recent decades, China has played a considerable role in some of the public exhibitions of plastinated bodies and body parts, and the commercial trade in organ donations. These contemporary developments have raised numerous challenging ethical and governance questions. In spite of the growing role of China in these, there have been few studies devoted to Chinese ethical thinking that might govern its policies on the use of human bodies and body parts, and in particular on the issue of commercialization. The present study is an attempt to bridge this gap, and concludes that Confucian thinking stresses the primacy of righteousness over profits and utilities. This conclusion is reached directly by drawing on Confucian ethical responses to the peculiar practice of using human body parts, such as placenta and flesh, as drugs in traditional Chinese medicine in imperial China and what has been called "yili zhibian," the major Confucian discourse on yi (righteousness or justice) and li (profit or interest) in its long history. The principle of prioritizing righteousness over profit leads to a general moral opposition to the commodification of human bodies and body parts. While Confucianism may not place an absolute prohibition on any such use, it does require that any commercial uses are made subject to the fundamental moral principles, such as righteousness, as well as adequate ethical governance procedures.