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Searching for Good Practice Recommendations on Body Donation across
Diverse Cultures
D GARETH JONES•
Department of Anatomy, University of Otago, New Zealand
Running title: Good practice recommendations
•Correspondence to: D Gareth Jones, Department of Anatomy, University of Otago,
PO Box 913, Dunedin 9054, New Zealand. Email: gareth.jones@otago.ac.nz
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Abstract
Good practice recommendations for the donation of human bodies and tissues for
anatomical examination have been produced by the International Federation of
Associations of Anatomists (IFAA). Against the background of these
recommendations, the ethical values underlying them are outlined. These are the
centrality of informed consent, their non-commercial nature, and the respect due to all
associated with donations including family members. The latter is exemplified in part
by the institution of thanksgiving services and commemorations. A number of issues
in the recommendations are discussed, including the movement of bodies across
national borders, donor anonymity, taking images of bodies and body parts, and the
length of time for which bodies can be kept. Outstanding questions in connection with
body donation include the availability of bodies for research as well as teaching,
allowing TV cameras into the dissecting room, and the display of archival material in
anatomy museums. Future prospects include whether IFAA could be formulating a
position on the public exhibition of plastinated human material, and in what ways
IFAA could assist countries currently dependent upon the use of unclaimed bodies.
Key words: IFAA good practice recommendations; body donation; ethical
values; donor anonymity; uses of donated bodies
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IFAA RECOMMENDATIONS
A number of papers in this issue have made reference to the IFAA (International
Federation of Associations of Anatomists) ‘Recommendations of good practice for the
donation and study of human bodies and tissues for anatomical examination’. These
were produced by me in consultation with others at the request of the executive
committee of the IFAA and appeared first in Plexus, the newsletter of the IFAA, in
August 2014 (IFAA, 2014). They were produced in order to outline what are regarded
as good practice guidelines. They are reproduced here in full.
The study of human cadavers is essential for teaching, advanced training and
research in medical and anatomical sciences. Institutions1 rely on the
donation of bodies by the general public, and are immensely grateful to
donors. However, it is imperative that institutions follow procedures of the
highest ethical standards in order to give donors full confidence in their
decision to donate. Transparency regarding the use of human material and
institutional procedures increases public trust and in turn increases public
support of body donation.
1. Informed consent from donors must be obtained in writing before any
bequest can be accepted.2 Consent forms should take into account the
following:
a. Donors must be entirely free in their decision to donate, this excludes
donation by minors and prisoners condemned to death.
b. Although not essential, good practice is encouraged by having the next
of kin also sign the form.
c. Whether the donor consents to their medical records being accessed.
1 The term “institution” is intended to refer throughout to a university, medical school
or anatomy department as appropriate.
2 This excludes the use of unclaimed bodies.
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2. There should be no commercialisation in relation to bequests of
human remains for anatomical education and research. This applies to the
bequest process itself, where the decision to donate should be free from
financial considerations, and also to the uses to which the remains are put
following bequest. If bodies, body parts, or plastinated specimens are to be
supplied to other institutions for educational or research purposes this may
not yield commercial gain. However, charging for real costs incurred,
including the cost of maintaining a body donation program and preparation
and transport costs, is considered appropriate. Payment for human material
per se is not acceptable.
3. There needs to be an urgent move towards the establishment of
guidelines regulating the transport of human bodies, or body parts, within and
between countries.
4. Specimens must be treated with respect at all times. This includes, but
is not limited to, storing and displaying human and non-human animal parts
separately.
5. The normal practice is to retain donor anonymity. Any exceptions to
this should be formally agreed to beforehand by the bequestee and, if
appropriate, the family.
6. Limits need to be placed on the extent to which images, or other
artefacts produced from donations are placed in the public domain, including
in social media, both to respect the privacy of the donor (and their surviving
relatives) and to prevent arousing morbid curiosity. No individual should be
identifiable in images.
7. A clear and rigorous legal framework should be established on a
national and/or state level. This legal framework should detail:
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a. The procedures to be followed in accepting bequests of human remains
for anatomical examination, including who is responsible for human remains
after death.
b. The formal recognition of institutions which may accept bequests,
which in some jurisdictions may involve licensing.
c. The safe and secure storage of human remains within institutions.
d. The length of time such remains will be retained by the institution.
e. The procedures to be followed in disposing of remains once the
anatomical examination is complete and they are no longer required for
anatomical education and research.
8. Institutional procedures should be formally established by an
oversight committee, which shall review the body donation program at
regular intervals. Such procedures should include the following:
a. Copies of the bequest should be retained both by the donor and by the
institution for whom the bequest is intended.
b. Records should be kept for a minimum of twenty years from the date of
disposal to ensure that human material can be identified as originating from a
specific donor.
c. Good conservation procedures should be employed throughout the
entire period during which the human remains are retained to ensure that the
most effective use is made of any bequest received.
d. Efficient tracking procedures should ensure that the identity and
location of all body parts from an individual donor are known at all times.
e. Facilities where cadavers are used must be appropriate for the storage
of human remains and secured from entry by unauthorized personnel.
9. There needs to be transparency between the institution and potential
donors and their relatives at every stage, from the receipt of an initial enquiry
to the final disposal of the remains. The clear communication of information
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should include but not necessarily be limited to the production of an
information leaflet (hard copy and/or digital), which could also help publicise
anatomical bequests and increase the supply of donors. This should set out the
following:
a. The procedures relating to registering bequests, acceptance criteria,
the procedures to be followed after death (including under what
circumstances a bequest might be declined), and the procedures relating to
disposal of the human remains. Sufficient grounds for rejection could include,
but need not be limited to:
•the physical condition of the body
•the virological or microbiological status of the donor in life
•the existence of other diseases (for example neurological pathology)
that might expose staff or students handling the body to unacceptable risks
•body weight or height over a specified limit
•the possible over-supply of donations at that institution at that time
•place of death outside the designated area from which bodies are
obtained.
b. The range of uses of donated bodies at that institution.
c. Possible costs, if any, that might be incurred by the bequestee’s family
in making a bequest, and the costs to be met by the institution accepting the
bequest.
d. Whether the donor’s anonymity will be preserved and whether their
medical history accessed.
e. Whether the body or body parts might be supplied to another
institution.
f. The maximum length of time the body will be retained, including any
legally sanctioned possibility of indefinite retention of body parts. The
relatives of the donor should be given the option of being informed in due
course of the date when the remains will be disposed of.
g. Donors should be strongly encouraged to discuss their intentions with
their relatives to ensure that their relatives are familiar with their wishes and
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that as far as possible those wishes will be carried out after death.
10. Special lectures/tutorials in ethics relating to the bequest of human
remains should be made available to all students studying anatomy. This is to
encourage the development of appropriate sensitivities in relation to the
conduct and respect that is expected of those handling human remains used
for purposes of anatomical education and research.
11. Institutions should be encouraged to hold Services of Thanksgiving or
Commemoration for those who have donated their bodies for medical
education and research, to which can be invited relatives of the deceased,
along with staff and students.
COMMENTS ON THE RECOMMENDATIONS
These Recommendations stand as an illustration of good practice; one could say ideal
practice. They were drawn up against a background of practice already in existence in
a number of countries in the West, and reflect what might be considered underlying
ethical values that should, and frequently do, motivate body donation. Their
underlying premise is that all bodies are donated, on the ground that the alternative,
use of unclaimed bodies, represents an ethically dubious practice that has on a number
of occasions in the past placed anatomists in untenable predicaments (Jones and
Whitaker, 2012). This, however, raises a legitimate query: if the use of unclaimed
bodies represents a dubious path ethically, where does this leave countries and
societies where bequests are rare or non-existent (regardless of the reason)? How are
anatomists to act in this situation? In an attempt to address issues of this nature, it is
important initially to re-visit the fundamental ethical values that underlie these
Recommendations.
Ethical values
The one value of pivotal importance to these Recommendations and that suffuses
most of the papers in this special issue of Clinical Anatomy is that of informed
consent. Once anatomists take this as a bedrock value for the use of human remains,
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the bodies routinely used in teaching and research will be those donated specifically
for these purposes. The use of unclaimed bodies will be viewed as ethically
compromised.
It should be noted that this statement reflects an ethical rather than a legal position. In
many jurisdictions the use of unclaimed bodies remains legal, but this does not abjure
anatomists from arguing that a more appropriate ethical path is that of bequests.
Anatomists should never rest easy in the knowledge that they are acting legally,
regardless of the nature of the legal position. Ultimately, they are moral agents who
have to take responsibility for the work they are doing and the resources they are
using.
A second strand within the Recommendations is that the donation of bodies is to
proceed within a non-commercial context. Human bodies and body parts are to be
donated altruistically. For-profit companies are not to be involved, since human
material is not to be sold (Champney, 2015). While charging for real costs raises no
ethical strictures, the distinction between real costs, payment and profit is a vexed
area. Expectations will vary enormously and negotiations between parties that are not
based on trust and honesty may degenerate into little more than a morass of
profiteering. This, in turn, is a recipe for public distrust of anatomists and the
anatomical profession, and distaste for what they are suspected to be involved in.
Without scrupulous oversight of all anatomical procedures, both administrative and
academic, anatomists could find themselves depicted as outlaws of respectable
society, as was the case in some instances in the early-mid nineteenth century
(Richardson, 2001; MacDonald, 2010). That would do a great disservice to the cause
of anatomy in both the dissecting room and the research laboratory, and would also
denigrate the efforts of most anatomists who function according to impeccable ethical
standards.
A third strand stemming from these values is that all involved in the donation contract
are to be treated with respect. This has implications for the way in which the families
of donors are brought into the negotiations from the earliest stages through to the
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death of the donor and the burial or cremation of the remains and possibly return of
the ashes. The details will vary depending upon cultural requirements and legal
stipulations. What matters is that there is transparency so that families know what is
happening. This will include providing criteria for rejecting bodies, what bodies will
be used for, and the length of time body parts will be retained. There may also be
demanding situations where immediate family members disagree on the donation or
on return of the ashes. Care is required that the anatomy department and its
representatives are seen to be acting in accordance with the Human Tissue Act under
which they are operating, but also with due care for the feelings and grief of close
relatives even when the problem stems from family disharmony.
These concerns for the family of the loved one have led to the institution of
thanksgiving services and commemorations. While these take a myriad forms
reflecting vast divergences in culture, religious stance and worldview, they share
common ground in their desire to acknowledge the inestimable gift of the donations.
In doing this students and staff who have benefitted show their respect for this gift,
and join with those responsible for providing it – the families and friends of the
donors as they reflect on the donors themselves. The wider community is also
involved, from the institution that assists financially in making the donation process
possible, to the surrounding society in providing a suitable legal context for the
donation of bodies for teaching and research. It is appropriate, therefore, that students
are instructed in the ethical reasoning behind donations, and the ways in which they
are to behave when dissecting and dealing with any human material. There should be
no question about students (and staff) behaving inappropriately in the dissecting room
if they have been inducted into seeing dissection as an ethical activity in which all are
responsible participants (Kahn and Gardin, 2015).
Points requiring further deliberation
Body bequests have generally been thought of in terms of providing bodies for use in
the region where they were donated. While the ‘region’ may vary considerably, it has
usually been within the country in question or within the state. It is often assumed that
those donating their bodies wish to assist those with whom they have dealings. While
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this may apply most obviously to the training of students, even research uses appear
to be on the part of researchers working locally. It may be objected that restrictions
along these lines are over interpreting donors’ motives, and are reading more into
them than can be justified. However, until this is shown to be the case, care needs to
be taken to ensure that bodies are not distributed more widely than provided for by the
consent of the donor and the expectations of family members. Care is also required to
check that legal stipulations are not breached, particularly where bodies are
transported across national borders.
The latter raises interesting ethical questions for anatomists and anatomy schools
where bodies from other countries are being used in the dissecting room. What is the
provenance of these bodies? How much is known about them, whether clinical
history, consent provided for the donation, and the donors’ expectations as to what
will be done to and with the bodies? These are not merely theoretical questions, but
are seminal to involving the students in ethical discussions as developing health
practitioners.
Donor anonymity has been central to dissecting room practice for many generations in
many countries. The Recommendations continue to advocate this practice, and yet no
rationale is provided. It is not accepted in some religious cultures where the family is
integral to the dissecting process, in that they hand over their deceased family member
whose relationship to the family is known and celebrated (Winkelmann and Gulder,
2004; Lin et al., 2009; Subasinghe and Jones, 2015). This has led to the concept of
cadavers as teachers, a concept that is spreading to other cultures, where the notion of
cadavers as first patients is gaining acceptance. In spite of these developments, there
has been no substantial debate on the merits or otherwise of these concepts, nor on
their ethical base. The breadth of informed consent would also have to be investigated
to assess how it would function in this new environment within pluralist and secular
societies.
A topic taken up in one of the papers in this collection is that of taking images of
cadavers and body parts (Cornwall et al., 2015). While Cornwall has opened up what
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he views as a growing area of concern within the digital era, the Recommendations
simply decree their inappropriateness in general. It is evident from Cornwall’s paper
that the opportunities for taking and spreading images have increased exponentially
and in an uncontrolled manner over the last few years. This is a debate that has barely
begun, and the in-depth discussion that needs to be held will have to be informed by
serious ethical analysis of its features. Banning taking images will not, and should not,
satisfy anatomists, unless supported by clear reasoning, and informed by the views of
potential donors and their families. Ultimately, there is no way of separating the
taking of images of bodies and body parts from knowing how the bodies were
obtained in the first place. If the bodies were unclaimed, who is to object to taking and
promulgating images since there is no one to contend for their remaining interests or
those of their (unknown) families?
Even in well-regulated institutions there are frequently unclear aspects to the bequest
process. How long can bodies or body parts be kept? Legislations vary, with some
stipulating time limits and others being more openended. Regardless of the precise
guidelines, issues arise with plastinated specimens and museum pieces, which may be
intended to contribute to ongoing museum collections. Along with these issues there
is the question of the disposal of such remains, especially plastinated ones. These
raise questions around institutional procedures covering record keeping, conservation,
and tracking of body parts and even tissue sections. Once again, there may be
different ways of coping with these challenges, but the message of this special issue
of Clinical Anatomy has been that their resolution has ethical dimensions.
Outstanding questions
Discussions along the lines of this paper as well as of most of those in this issue raise
questions that have been little debated in the literature. While I have largely confined
my attention to the IFAA Good Practice Recommendations in this paper, a number of
them lend themselves to ongoing analysis. These were touched upon in the preceding
section. In additon to these, there are further issues that have featured to only a very
limited extent in the anatomy/ethics literature. I shall do no more than outline these
for future discussions.
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First, should bodies bequeathed to Anatomy Departments be available for research as
well as teaching? If they are to be available for research, should additional consent be
required at the time the bequest is made? Assumptions are currently made that this is
the case, and the public appears to have a very broad view of what constitutes
‘research’ (Fennell and Jones, 1992), but clarity and transparency would be good
practice.
How much should those interested in bequeathing their bodies be told about what will
be done to their bodies in the Dissecting Room? In other words, should consent
involve a detailed run down of the dissecting room processes? Is this unnecessary?
Books and a film have specified what happens and there is no evidence that they have
done any damage to the donation ethos (Hafferty, 1991; Carter, 1997; Montross,
2007; Trotman, 2011).
Should TV cameras be allowed into the Dissecting Room (with appropriate
stipulations). If not, why not? This has been done (Trotman, 2011) and the resulting
film was very favourably received. It is one means of breaking down the mystique of
the Dissecting Room (and perhaps of Anatomy), and once again one needs to enquire
whether there are convincing ethical reasons to keep it this way. This query is related
to the question of the public display of plastinated and dissected bodies, about which
there have been numerous responses (see Jones, 2015).
Should Anatomical museums continue to display specimens that were obtained many
years ago without consent? This introduces the matter of the use of archival material
(Jones et al., 2003). While there has been considerable debate on this matter,
especially in relation to indigenous skeletal remains, it has not featured prominently in
the anatomical literature.
In another paper in this special issue, I have asked the question whether plastinates
with all their various uses have improved the ethical standing of Anatomy, or have
they done it ethical damage (Jones, 2015)? While the major spotlight has been placed
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on the public exhibitions of whole body plastinates, it is of more general applicability
across anatomy. This is because plastinated material a far more permanent character
than material prepared using more conventional fixation techniques.
IFAA Recommendations and the future
Against this background of some of the features of the IFAA Recommendations two
questions emerge:
• Should the IFAA be formulating a definitive position regarding human exhibitions
such as Body Worlds?
• Should the IFAA be considering the possibility of establishing guidelines to assist
countries currently dependent upon the use of unclaimed bodies arrive at appropriate
legislation regarding the treatment of human remains?
As attempts are made to address these questions, policy makers will be confronted
with the question of how much compromise to accept on practices that are thought to
be ethically substandard or unacceptable? What degree of pragmatism is in order on
the path to more acceptable policies? These are questions for ongoing discussions by
the IFAA and anatomy departments worldwide.
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Carter AH. 1997. First Cut: A Season in the Human Anatomy Lab. New York:
Picador.
Champney TH. 2015. The business of bodies: Ethical perspectives on for-profit body
donation companies. Clin Anat. this issue.
Cornwall J, Callahan D, Wee R. 2015. Ethical issues surrounding the use of images
from donated cadavers in the anatomical sciences. Clin Anat. this issue.
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Fennell S, Jones DG. 1992. The bequest of human bodies for dissection: A case study
in the Otago Medical School. NZ Med J 105: 472-474.
Hafferty FW. 1991. Into the Valley: Death and the Socialization of Medical Students.
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