Dissection and Ethics. Who Makes the Call?
It can be hard for someone not invested in the process, to understand why dissection is either necessary, or what the process entails. There is understandably, an emotional component surrounding the fact that the cadavers we are dissecting are people who gave their bodies up specifically for the purpose of learning, study and enquiry. For the most part this emotion comes not from the potential donors themselves but from the sensitivities of those dealing with the business of who should or shouldn’t be allowed in a dissecting room.The acting principle of the most noble of gifts, donating your body after your death, is that someone learns from the donor, then goes away and benefits others from that learning. The act of learning in this instance thereby becomes of itself altruistic. We learn that we may in some way be of service to others. That we may help them ourselves either by treating them, teaching them or even understanding them better. We are elevated both by the learning and the teaching. Who is the learner? Or more saliently, who has the right to learn from this gift? Should it solely be young student doctors or surgeons? Well for the most part it is.
But what about those who work in other fields? Those who help others to move and therefore ultimately retain the ability to move later in life. Pilates instructors, Yoga teachers, personal trainers? Then there is the person that touches the body with the view of healing it, or easing the trials of a human existence. This generally is not the medical doctor, who rarely these days touches from the perspective of intent of change or who uses touch as a therapeutic tool, but instead palpates to diagnose the disease, assess its progress and define its treatment. By their own admission, many GP’s undergraduate anatomy study is going to be a distant memory. Those who spend their days working with the anatomy of the human form, Physiotherapists, massage therapists, acupuncturists, osteopaths, chiropractors, Bowen therapists and so forth are people who are often at the top of their game anatomically speaking.
These are people who deal with the body in a more direct, functional and holistic way than most doctors will ever end up doing. They touch, palpate, feel and spend extended periods of time trying to understand textures and changes underneath their hands. All of them will have learned most of their anatomy from a book and assume that this is reliable. Should they be allowed to study the body that has been donated for the purposes of study? Is their mission; keeping people mobile, fit and healthy, or rehabilitating those who have suffered loss of movement, any less noble or worthy than that of the doctor or surgeon working with disease and illness? Should they be able to have carefully guided and managed access to the dissection room? If not, why not? Some of the practices above can involve deep pressure into soft tissues and adjustments to bones, mobilisation of injured tissue, penetration with needles and so forth: all of which carry potential risks.
Apart from that is the method of dissection itself. The standard approach is great anatomically, but loses huge amounts in the translation from anatomy to function. This is where our dissections come in and there is simply no-one in the UK that is or is even capable of dissecting in the way that I do. Not because I have any particular skill as a dissector, but because the thought process from the outset is totally different.
So what’s the law and what are the ethics? The law is covered fairly well. There are regulations the Human Tissue Act 2004 and a regulator, the Human Tissue Authority – HTA. Each establishment involved in work with Human Tissue is required to be licensed and requires a Designated Individual a DI to effectively run the place as well as a license holder. There are regular inspections and the whole process works well. The DI has to be approved by the HTA and hold certain qualifications and have an appropriate background. The Act and thereby the authority, doesn’t restrict who can study or what they can or can’t do. It works to protect donors and their families, ensures that the proper process takes place and that the donation process is, from start to finish, robust and transparent. Inspections of licensed premises ensure that nothing is taking place which is likely to infringe the act and the regulator has powers to close premises which do not comply.
The regulator enforces the act which is an act of parliament, a representative body of the electorate. Parliament and thereby the people therefore do not say that only certain section of the professional populace can study anatomy. That decision is down to each university or hospital and those who run them. The approaches from these institutions will vary widely and fear of offence will be a guideline to those creating policy. It was ever thus. Indeed it was public offence and pressure gave rise the original Anatomy Act of 1832, in the face of body snatchers and murders to order. The appalling scandal at Alder Hey prompted the new act and the formation of the regulator.
The scandal at that time however was not about the donation of bodies for teaching or who should be taught, but the retention of children’s organs by one pathologist in particular. The fear remains among some, that the donation programmes would dry up if it came out that donors were being used to train people who were not ‘medically trained’ or who work with back pain for instance. The fear has never been based on any kind of reason, investigation or logic nor from any clear ethical standpoint but seemingly on fear of judgement and a desire to avoid controversy.
When Gunther Von Hagens first brought his Bodyworlds exhibition to the UK, the press was and still is ‘outraged’ as only the press can love to be. The public response? They queued around the block for hours and body donations went through the roof. Von Hagens has thousands on his list waiting to donate their bodies. Tell the public that you were using donors to try and find treatments for back pain and the response would probably be the same. The key to overcoming any issues from the side of a teaching establishment is to better communicate with the donors. What does a donor think will happen to them? What restrictions would you put on your body being used to teach anatomy? Having spoken to many people who have become donors over the years, they have all said things along the following lines.
An article from the Guardian last year illustrates this as well “I don’t really care what you do with my body when I’m dead. As long as someone is learning from it, that’s all I care about. I don’t need it and if someone can make good use of it, then good luck to them.” Their donation is never conditional or judgemental and they trust that the right thing will be done for them and their families when the time comes.
It’s what constitutes the ‘right thing,’ that causes the problem, particularly if addressed from a fear of doing the ‘wrong’ thing. It therefore behoves the universities to take a robust stance about who they teach when challenged by those who might not have a complete understanding of the use of donated bodies. The understandable temptation is to close the doors and the ranks and exclude those that might not at first glance conform to the standard academic mould. The decisions made are not clear cut and there are no guidelines in place to help DIs – who have the final say do – make an ethical or even logical decision.
There are many reasons why privately funded courses are a boon to universities and teaching hospitals and a sensible approach would be to keep the options open.
For a myriad of reasons, donor bodies are regularly albeit reluctantly, not accepted. Being significantly overweight, having certain medical conditions that might alter your normal anatomy, and lots of surgery, might mean that the donor gift isn’t suitable for learning by medical students. Sometimes the university is full and just can’t take the body. A bodyworkers dissection course such as mine will often use material that would otherwise not be used by the university and would have to be returned to the family, against the wishes of the deceased. Shorter classes will also often use material that would not otherwise be fully used by the medical students. These classes are also generally run out of normal term times, making use of facilities that would otherwise be idle and generating significant additional income at the same time.
This money goes to create better learning resources for medical students in times where extra funding is thin on the ground. So where do the ethics lie? Vigilance and the need to exclude those whose motives are less than honourable is a given. But anatomy is not a domain possessed solely by medicine. A human body is one thing that we all have in common, owned by us all and a genuine interest in learning as much as we can about how this magnificent piece of machinery operates, with the genuine intent to use this knowledge for the benefit of others, is a noble calling.
No-one who attends a dissection class with me is doing so to pass an anatomy exam. They are doing it because they work with the human form every day. They work with people in pain or with people trying to stay mobile or with the elderly. They want to study the deceased body in order to directly benefit their living clients. This is surely why donors donate in the first place?