History and Ethics of Anatomical Dissection

History and Ethics of Anatomical Dissection
Sabine Hildebrandt, MD Boston Children’s Hospital/Harvard Medical School History & Ethics of Anatomy Hildebrandt

History & Ethics of Anatomy Hildebrandt
Addressing ethical questions in medicine and anatomy by studying the history of anatomy 1. Why do anatomists need to dissect? Do they? 2. Where do the bodies come from? 3. Do dead bodies deserve respect? 4. How do dissectors save their humanity? Anatomy is an important foundational science in medicine. Ethical questions associated with this discipline can be addressed by studying the history of anatomy. Examples from this history illustrate the most prominent problems in anatomy: Why do anatomists need to dissect and do they really have to do it? Where do the bodies come from that are used in teaching and research? Do dead bodies deserve respect, do they have dignity? How do dissectors save their humanity? History & Ethics of Anatomy Hildebrandt

provides knowledge of the structure and function of the human body has become “a vehicle for moral and ethical education” in the perception of students of anatomy (Dyer and Thorndike, 2000; Goddard, 2003) The medical discipline of anatomy provides knowledge of the structure and function of the human body. However, in the last decades it has also become “a vehicle for moral and ethical education” in the perception of students of anatomy. Often they are confronted with the reality of death for the first time. This and the dissection itself leaves them anxious and open to questions of the rightness of their doing: cutting into intact human bodies, disassembling them. Andreas Vesalius ( ) De Humani Corporis Fabrica Libri Septem  (Basileae : ex officina Ioannis Oporini, 1543) History & Ethics of Anatomy Hildebrandt

Vesalius Juan Valverde Hans von Gersdorf 16th century anatomists ana-temnein: Greek for ‘to cut apart’, dismemberment The word “anatomy” itself is based on the Greek word root “ana-temnein”: to cut apart. And indeed, the dissection of a human body is a dismemberment not usually tolerated by society. The examples of images from early anatomical atlases here seem cruel and brutal to the casual observer, but are meant to be learning tools for the student of anatomy- one of the many ambiguities new students are confronted with. How is the same thing acceptable within the realm of medicine/anatomy, while it is completely unacceptable outside this field in the rest of world, where it is indeed a taboo? History & Ethics of Anatomy Hildebrandt

Ethical issues in anatomy (1) Central ethical problem of anatomy: The paradigm that knowledge has to be gained by dissection, that is: by breaking the taboo of violating the integrity (and privacy) of a person’s dead body. Thus the central ethical problem of anatomy is the paradigm that knowledge has to be gained by dissection of the dead human body, an activity that stands in contrast to the taboo that forbids the violation of the integrity and privacy of a dead person’s body. This paradigm of the need for dissection has been questioned in the last decades with the advent of three-dimensional imaging of the human body and other new technologies. Still, many anatomists and students still adhere to the traditional paradigm. However, the “perversity” or exceptional situation of anatomical knowledge gain by dissection of the dead is often very apparent to the new student. This sensibility is not owned only by contemporary students, as the following examples from 2012 and 1940 show. History & Ethics of Anatomy Hildebrandt

this will be my first experience with human dissection. it seems like medicine is full of so many tradeoffs where there is an exchange of some harm for a greater good, […] even in medical techniques like chemotherapy. is dissection similarly an infliction of harm for the sake of the greater good? we will be cutting open bodies, human bodies, that housed people like me, like my mom, like my dad. who lived inside this body? what were they like? what feelings,memories,lessons,experiences were consolidated inside this body? now we will cut it open, not to explore and cherish those contents, but for the sake of anatomical knowledge that will hopefully allow us to eventually take better care of our fellow humans, like my mom, my dad, and the person who was inside this body... i hope that tradeoff is worth it. this will be my first experience with human dissection. it seems like medicine is full of so many tradeoffs where there is an exchange of some harm for a greater good, […] even in medical techniques like chemotherapy. is dissection similarly an infliction of harm for the sake of the greater good? we will be cutting open bodies, human bodies, that housed people like me, like my mom, like my dad. who lived inside this body? what were they like? what feelings,memories,lessons,experiences were consolidated inside this body? now we will cut it open, not to explore and cherish those contents, but for the sake of anatomical knowledge that will hopefully allow us to eventually take better care of our fellow humans, like my mom, my dad, and the person who was inside this body... i hope that tradeoff is worth it. This is the statement of a medical student who was asked to voice his thoughts and expectations concerning the anatomical dissection course a few weeks before the start of his medical studies. He addresses several of the central ethical questions in medicine and anatomy: the ambiguity of “tradeoffs” for the greater good of the patient; the identity of the body donor; the realization of the physical reality of the body that will no longer be cherished for itself but for its contribution to the gain of anatomical knowledge. Medical student, Class of 2016 History & Ethics of Anatomy Hildebrandt

Why did we assume to have the right to snip away at the mortal remains of human beings? Did not this man whom I was supposed to ‘dissect’ also have a name before? Who was he? What was his name? Of course, these were only the ‘mortal remains’, not the human being he was before. Did this ‘specimen’ represent nothing other than a piece of chemically treated flesh, an object or thing, with which one may do as one pleases? Hadn’t humans from time immemorial- ultimately into the present- demanded something like piety towards the dead and honored them in cultural rites like for example a burial? Why did we assume to have the right to snip away at the mortal remains of human beings? Did not this man whom I was supposed to ‘dissect’ also have a name before? Who was he? What was his name? Of course, these were only the ‘mortal remains’, not the human being he was before. Did this ‘specimen’ represent nothing other than a piece of chemically treated flesh, an object or thing, with which one may do as one pleases? Hadn’t humans from time immemorial- ultimately into the present- demanded something like piety towards the dead and honored them in cultural rites like for example a burial? These are the words of Stephan Pfürtner ( ), theologian and social ethicist. He started his medical studies in Breslau/Wroçlaw in 1940 after having served as a soldier on the Eastern front in World War II. On his first encounter with the bodies in the dissection course he experienced several “shock-seconds”, as he called them, but suppressed any signs of emotion, remembering his encounters with bloody bodies in surgery during his war service. This coping behavior of so-called “clinical detachment” will be discussed later. Stephan Pfürtner, , theologian and medical student in Breslau/Wroçlaw 1940 History & Ethics of Anatomy Hildebrandt

Ethical issues in anatomy (2): Where do bodies come from? as “medical ethics is about things done to the human body” (Barilan, 2005) anatomy needs to answer questions about the ethics of body acquisition for dissections Whereas questions of the identity of the body to be dissected are often foremost in the beginners mind, a mention of the “sources” of body procurement in anatomy or of the provenance of human “material” in scientific publications or anatomical collections is relatively rare. However, as “medical ethics is about things done to the human body” (Barilan, 2005), anatomy needs to answer questions about the ethics of body acquisition for anatomical purposes. History & Ethics of Anatomy Hildebrandt

Sources of bodies for anatomical dissection in history: Bodies of the executed Bodies stolen from graveyards Bodies of persons murdered and sold for the purpose of dissection Bodies of suicides Bodies of duelists Bodies of “public women” and “unwed mothers” (Germany) Unclaimed bodies from poorhouses, mental institutions, hospitals, prisons Donated bodies Sources for anatomical body procurement included over time all of the following: Bodies of the executed Bodies stolen from graveyards Bodies of persons murdered and sold for the purpose of dissection Bodies of suicides Bodies of duelists Bodies of “public women” and “unwed mothers” (Germany) Unclaimed bodies from poorhouses, mental institutions, hospitals, prisons Donated bodies History & Ethics of Anatomy Hildebrandt

for anatomical dissection in history
Sources of bodies for anatomical dissection in history period: - bodies of executed criminals - bodies robbed from graves During the first and historically longest period the only sources of bodies for for anatomical inquiry were those of executed criminals and bodies robbed from graves. Park has pointed out that there were also more informal, quasi private explorations of anatomy that happened within the realm of religious ceremony, childbirth and death chambers (Park, 2006). The following discussion focuses on the formal, official anatomical dissections. History & Ethics of Anatomy Hildebrandt

First human dissections in Alexandria, around 300 BC Herophilus of Chalcedon, BCE The first known human dissections for anatomical inquiry were carried out by Herophilus of Chalcedon ( BCE) and Erasistratos of Chios ( BCE) in Alexandria/Egypt. Apparently they were the first to procure societal acceptance for the breaking of the taboo of not violating the intact human body in order to gain anatomical knowledge. The Ptolomean rulers of the time were enlightened and enabled these dissection by allowing the anatomists the use of the bodies of executed criminals. Erasistratus of Chios, BCE History & Ethics of Anatomy Hildebrandt upload.wikimedia.org/ wikipedia/en/thumb/6/66/.. issue1/ipc jpgwww.culture.gouv.fr/ ENSBA/Icones/Guillemot.gif

Galen ( CE) Roman physician wrote on all aspects of medicine, including anatomy; no human dissection The next important gain of anatomical knowledge came 400 years later with Galen ( CE), a Greek born physician who practiced in Rome. He wrote many volumes on various aspects of medicine, including his theory of pathogenesis based on the balance of the four humours. His work on anatomy was detailed, but based on the dissection of animals. He did not break the taboo of the inviolate human body. Consequently some of his erroneous anatomical statements continued in official medical teaching for the next thousand years, as Galen’s books were the basis of all formal medical education for another millenium.. History & Ethics of Anatomy Hildebrandt opioids.com/ opium/galen.jpg

Mondino de Luzzi ( CE) Public dissections Bologna, Italy In the early Rennaisance, Mondino de Luzzi ( CE) reintroduced the dissection of human bodies. His work was sanctioned by the Vatican. The latter had already allowed autopsies performed in cases of suspected poisoning. Mondino’s dissections were staged publicly, with students and a general audience present. History & Ethics of Anatomy Hildebrandt medinfo.ufl.edu/other/ histmed/rarey/images/14.jpg

City of Padua, Italy 1539: bodies of the executed for Andreas Vesalius ( CE) First author of a comprehensive and systematic view of human anatomy, revolutionized the field. Two hundred years later Andreas Vesalius ( CE) became the best known representative of a new scientific anatomy that explored the human body systematically. He documented his work in a first comprehensive and exact atlas of the human body History & Ethics of Anatomy Hildebrandt

The bodies of the executed were the first legally assigned source
of bodies for anatomical dissection Scotland 1506 England 1540 Prague 1600 Bodies of the executed were the first legally available source for anatomical body procurement. This map shows the universities and dates of the introduction of legislation concerning the use of executed criminals by anatomists. The earliest law was passed by Frederic II of Italy, who granted the use of 1 body every 5 years for the use of the anatomists. The numbers of executed persons tended to be small, so that the anatomists usually continued to rely on the illegal acquisition of bodies by graverobbing. Salerno 1241 Giessen 1676 Padua 1539 Florence 1387

Anatomical dissection as part of capital punishment William Hogarth: The rewards of Cruelty, 1751 William Smith, murderer, 1750: “As to my corporal frame […] I can not refrain from anxiety, when I think how easily this poor body […] may fall into possession of the surgeons, and perpetuate my disgrace beyond the severity of the law.” (Hunter, 1931) Academic anatomical dissections were frequently open to the (paying) public and associated with great dishonor for the dissected in the mind of the general population. The dissection was felt to “violate [d] both its [the corpses] personhood and its social identity by rendering it unrecognizable and unsuiting it for a conventional funeral” (Park, 2006). In the late seventeenth and throughout the eighteenth century legislators took advantage of this public perception by using the threat of dissection as a deterrent measure to committing serious crimes. Anatomical dissection became part of the capital punishment, for example with the so-called “Murder Act” of 1752 in Britain (Richardson, 1987). Certain crimes became “punishable by dissection” and the anatomy of this time presented itself as an “ ill-defined (...) mixture of punitive and medical purposes” (Sappol, 2002, p 102). The addition of anatomical dissection as punishment was considered more frightening and ignoble by many offenders and their families than the execution itself (Hunter, 1931). History & Ethics of Anatomy Hildebrandt

Sources of bodies for anatomical dissection in history 2. period: unclaimed bodies, end of 17th century and after This attitude towards dissection started to change in the eighteenth century with an increasing public interest in the sciences. Anatomy flourished in Europe and the body supply from executions did not satisfy the increasing needs of medical schools, especially as execution rates had started to drop in some countries . Consequently, governments on the European continent passed legislation allowing the use of the unclaimed bodies of “paupers,” inmates of prisons and psychiatric and charitable hospitals for dissection. These regulations frequently continued to include the use of the bodies of the executed. By the end of the eighteenth century the availability of unclaimed bodies alleviated the shortage of the body supply for anatomical dissection on the European continent. History & Ethics of Anatomy Hildebrandt

delivery of bodies of the executed
1730: Halle, Germany delivery of bodies of the executed and of the poor or imprisoned to the department of anatomy at the University of Halle Department of Anatomy, Halle 1742: Maria Theresia, Austria delivery of the bodies of the executed and the poor to the department of anatomy in Vienna These are two examples of the new legislation concerning unclaimed bodies for anatomical dissection. In 1730 the local authorities in Halle allowed the delivery of bodies of the executed and the poor or imprisoned to the department of anatomy at the University of Halle. In 1742 Empress Maria Theresia of Austria passed a similar law for the University of Vienna. History & Ethics of Anatomy Hildebrandt m/meytens/2maria_t.jpg 561/st_Anatomie.jpg

Grave-robbing became a constant problem in Britain in the late 18th and early 19th century due to a lack of legislation concerning unclaimed bodies. Same for the US and its emerging anatomical education in the 19th century. The situation was different in Great Britain where legislation concerning the use of unclaimed bodies was not yet introduced by the beginning of the nineteenth century. Grave robbing had become a common practice and even murder for dissection occurred, eliciting public and sometimes violent outcries against anatomists. The images show a scene of grave robbing and a so-called “mort-safe”, a fortification of the grave that was supposed to make grave robbing impossible. These fortifications were expensive and the poor could not afford them. To resolve the grave robbing situation, the British government passed the Warburton Anatomy Act in 1832, which provided the use of the poor and unclaimed for anatomical dissection, but excluded the use of the bodies of the executed. At the same time the Anatomy Act allowed for body donations. Other countries belonging to the British Commonwealth followed with similar legislation. In the US legislation concerning unclaimed bodies was decided by individual states, and grave robbing remained a problem until the early 20th century. History & Ethics of Anatomy Hildebrandt archive.student.bmj.com/.../ life/images/04.jpg

Sources of bodies for anatomical dissection in history 3. period: body donation programs, 2. half of 20th century Decreasing number of unclaimed bodies - Medicine becomes effective - Rise of body donation programs, based on state and federal laws: based on the concept of individual human rights, human dignity and voluntary decisions for donation. Two driving forces can be identified behind the establishment of body donation programs: the decreased availability of unclaimed bodies and the change in public opinion concerning modern medicine. The combination of an improvement in general health of the population as well as better burial benefits led to a decrease of unclaimed bodies from public institutions by the middle of the twentieth century. While sporadic body donations had been known to occur in Europe and the US in the 18th and 19th century, these were usually individual donations from anatomists, doctors and prominent individuals. With the rise of better education of the public as well as the increasing success of modern medicine, especially in transplantation medicine, the general opinion towards scientific medicine including anatomy changed in the middle of the 20th century, so that the concept of individual body donation started to find wide acceptance. In 1954, ten U.S. states had provided statutes for legal body donation. In 1963, Jessica Mitford published a scathing criticism of the U.S. American funeral industry and pointed out alternatives to commercial burials. Among them she mentioned anatomical body donation and included the first list of U.S. medical schools that accepted such donations. Her book was widely received and may have been one of the factors helping to popularize body donation as an alternative to traditional burial. In 1968, “The Uniform Anatomical Gift Act” was formulated by the National conference of the Commissioners on Uniform State Laws; it established the human body as property and that a donor’s wishes for its disposal superseded those of his or her next of kin. By February 1972, 48 U.S. states had accepted the act and today all states in the U.S. have adopted it. All U.S. medical schools accept body donations, but some still have to supplement their supply of donated bodies by the use of unclaimed bodies. Warner identifies the Uniform Anatomical Gift Act of 1968 as the cause for a “watershed in the social origin of the cadavers” in anatomical dissection. He sees the use of donated bodies as transforming the subjective experience of human dissection and the relationship between dissector and dissected (Warner, 2009, p 28). The dissected is no longer one of the disenfranchised of society but a voluntary true donor of knowledge and recognized by the dissector as such. History & Ethics of Anatomy Hildebrandt

Discriminatory practices in anatomy: the use of bodies provided through questionable legal sources Historical examples: - Use of bodies of the poor, e.g. in 19th century England (Richardson, 1987) - Use of bodies of “the poor, the black and the marginalized” in 19th century US anatomy (Halperin, 2007) - Use of bodies of victims of National Socialism in Germany Modern examples: - Use of the body of an executed man for the Visible Human Project - Use of bodies of Chinese executed persons for anatomical exhibits The discriminatory practices in anatomy Warner was referring to were the use of the unclaimed bodies of the poor whose families could not afford to bury them, e.g. in 19th century England (Richardson, 1987) and also in the US. Here the discrimination especially concerned the disproportionately high number of bodies of African-Americans. Another example is the use of bodies of victims of the National Socialist government in Germany between 1933 and Modern cases of discrimination are, among others, the use of the body of an executed man in the Visible Human Project and the use of the bodies of Chinese executed prisoners for travelling anatomical exhibits of plastinated specimens. It has to be pointed out that all of these sources were legal at the time or still are in the case of the modern examples. However, legality is not synonymous with ethical correctness. History & Ethics of Anatomy Hildebrandt

Results from an archeological excavation of the dissection rooms at the Georgia Medical College: Skeletal remains from dissections : 79% from African Americans, who made up 42% of the general population 21% from Euro-Americans, who made of 58% of the general population (Blakely and Harrington, 1997) “In Baltimore the bodies of coloured people exclusively are taken for dissection, because the whites do not like it, and the coloured people cannot resist” Harriet Martineau 1838 English travel writer, quoted after Halperin, 2007 An archeological excavation of the dissection rooms that were used at the Georgia Medical College between 1840 and 1880 found that the skeletal remains unearthed there were mostly those of African Americans (79% versus 42% in the general population), whereas there were disproportionately few remains of Euro-Americans among the bones (21% versus 58% in the general population). Harriet Martineu, a British travel writer, remarked in 1838: “In Baltimore the bodies of coloured people exclusively are taken for dissection, because the whites do not like it, and the coloured people cannot resist” (quoted after Halperin, 2007). History & Ethics of Anatomy Hildebrandt

A similar situation existed at the Medical College of Virginia in the late 19th century. There, as at the Georgia Medical College, an African American janitor was responsible for body acquisition, which was a difficult task due to a lack of appropriate legislation. Scandals ensued, among them the fate of the body of Solomon Marable, which Chris Baker had acquired after the execution. This was apparently against the will of the public, which protested. These types of situations only changed with the advent of functional anatomical acts of legislation and finally with the introduction of body donation programs. Medical College of Virginia: Janitor Chris Baker transported the body of executed prisoner Solomon Marable, packed in a barrel of salt. Citizens tried to reclaim the body. History & Ethics of Anatomy Hildebrandt

German Anatomy during National Socialism, Use of bodies of victims of National Socialism for anatomical purposes: teaching and research 2. Ethical transgression of basic paradigm in anatomy: work with the dead, to new paradigm: work with the “future dead”, i.e. medical experimentation The National Socialist period from 1933 to 1945 became an especially dark time for German anatomy, which until then had been one of the leaders in the field. Anatomists failed doubly in terms of medical ethics. Firstly, they used many thousands of bodies of victims of National Socialism for teaching and research purposes. And secondly, they transgressed ethical boundaries by leaving behind the basic paradigm of anatomical inquiry, which is the gain of knowledge by working with the dead, and instead worked with the “future dead” in performing experiments on prisoners who were subsequently murdered. “Justifizierter” [“executed man”], Metzenbauer, 1942 History & Ethics of Anatomy Hildebrandt

Changes in traditional sources for bodies in anatomy in NS period Traditional source New: NS victims Deceased psychiatric patients - include “Euthanasia” patients Suicides increasingly Jewish citizens Deceased prisoners - new NS laws + increased violence - GeStapo prisoners - concentration camp inmates - forced laborer camp inmates - prisoners of war Executed persons - high numbers due to NS laws - women (incl. pregnant women) Deceased hospital patients Estimated 35,000 total body supply, percentage of victims unclear All of the traditional sources for body procurement were available during the Third Reich, however they changed in character and included great numbers of victims of the National Socialist regime. Among the psychiatric patients were now the bodies of patients who were killed within the so-called “euthanasia” programs. Among the persons committing suicide were increasing numbers of Jewish citizens who sought this desperate solution to their persecution. The same is true for many prisoners who committed suicide. Following the National Socialist laws there were many more political prisoners or those imprisoned for minor crimes. They were victims of excessive violence, which often led to their death. The GeStapo delivered the bodies of persons killed by it directly to the anatomical departments. Deceased prisoners from the various new types of camps were also brought to the anatomical departments. Execution rates soared, exponentially so during the war. While during the Weimar republic less than 300 men had been executed, the numbers during the NS period rose to a minimum of 16-17,000 executions following civilian court trials and at least as many after military proceedings. Among the executed were now also women, who had not been executed during the Weimar Republic, and among the women were even pregnant women. It is unclear how many of the estimated 35,000 bodies delivered to German anatomical departments between 1933 and 1945 were those of victims of the regime. History & Ethics of Anatomy Hildebrandt

“[…] I was the only living soul in this hall. The yellow emaciated bodies, bodies of deceased prisoners and executed persons lay there […]. The face looked without expression to the ice-covered attic window, the closed mouth was like a narrow, blue streak. No pain was in his features. I stared at the eyes. They were empty, asked no questions, gave no answers. One body looked like another. Still, they all had once been living human beings, like Frederick, like Björn, like- me. They had waited, despaired, and still with hope in their hearts, this spark of hope that stays with us until the last breath” Medical students had to work with these bodies. Hiltgunt Zassenhausen started her medical studies in Hamburg around She was an interpreter of Scandinavian languages and helped prisoners by smuggling food and messages. She survived the war. She remembered the victims’ bodies she had to dissect as they were lying in the dissection room at Hamburg university: “[…] I was the only living soul in this hall. The yellow emaciated bodies, bodies of deceased prisoners and executed persons lay there […]. The face looked without expression to the ice-covered attic window, the closed mouth was like a narrow, blue streak. No pain was in his features. I stared at the eyes. They were empty, asked no questions, gave no answers. One body looked like another. Still, they all had once been living human beings, like Frederick, like Björn, like- me. They had waited, despaired, and still with hope in their hearts, this spark of hope that stays with us until the last breath.” Hiltgunt Zassenhausen, medical student Hamburg/Germany Memories of the dissection labs, ca. 1942 History & Ethics of Anatomy Hildebrandt

National Library of Medicine’s Visible Human Project (male) The visible human data set: an image resource for anatomical visualization: -CT/MRI, cryosections One of the few well-documented cases of the use of bodies of the executed in modern anatomy is Robert Jernigan from Texas, whose body was used for the National Library of Medicine’s Visible Human Project. During the 1980’s the National Library of Medicine decided to create a Visible Human Data Set as part of a new biomedical library. The goal of the approach was to obtain digital images of computer-assisted tomography (CT) scans, magnetic resonance imaging (MRI) scans and cryosections of a “representative, carefully selected and prepared male and female cadaver”. A contract was awarded to the University of Colorado at Denver in 1991. History & Ethics of Anatomy Hildebrandt

“What we were searching for was someone 21- to 60-years of age who died without traumatic injuries or invasive or infectious disease. We got lucky. Some inmates on death row in Texas had decided to donate their bodies to science. They were young, relatively healthy men whose organs, tainted by lethal injection, were rendered unsuitable for transplant. Through screening of cadavers such as these as well as individuals from other donations, our panel selected the body of a recently executed 38-year-old male. It was not lost on us that victims of executions, a population that taught anatomist’s [sic] centuries ago, would be teaching us once again, perhaps in some way repaying society for their crimes.” Spitzer and Whitlock, 1998 The search for appropriate cadavers proved to be the most time-consuming part at the start of the project (Spitzer and Whitlock, 1998), as the researchers had to wait for “the right combination of willing donor, prompt notification of death, desired state of whole-body anatomy and rapid decision making capability” (Spitzer and Scherzinger, 2006). “What we were searching for was someone 21- to 60-years of age who died without traumatic injuries or invasive or infectious disease. We got lucky. Some inmates on death row in Texas had decided to donate their bodies to science. They were young, relatively healthy men whose organs, tainted by lethal injection, were rendered unsuitable for transplant. Through screening of cadavers such as these as well as individuals from other donations, our panel selected the body of a recently executed 38-year-old male. It was not lost on us that victims of executions, a population that taught anatomist’s [sic] centuries ago, would be teaching us once again, perhaps in some way repaying society for their crimes.” (Spitzer and Whitlock, 1998) History & Ethics of Anatomy Hildebrandt

Joseph Paul Jernigan, executed for murder on August 5, 1993, in Texas “legal” use, hence “ethical” “excellent material for the construction of the visible human” These conditions were met by the donor for the male body, Joseph Paul Jernigan, a 38-year-old convicted murderer. He was executed by court-ordered lethal injection at 12:31 AM on August 5, 1993 and his body was received by anatomists 90 minutes later. Mr. Jernigan was one of several Texas death row inmates who had willed their bodies to science after prompting by a prison chaplain to contribute to society by this gesture. The ethical feasibility of the project was discussed by anatomists, ethicists and the Texan authorities, and the investigators were given permission to proceed. It was intended to keep the identity of the “Visible Male” anonymous, but reporters were able to identify him after the time, place and manner of his death were published. Mr. Jernigan’s motivation for the bequest of his body to science has been reported variously as either wanting to save his family the cost of the burial, to bring something good to society after a life of crime or to become famous. This case opens up many questions: The problem of capital punishment per se Is their “free will” on death row? Why was Mr. Jernigan allowed to donate his body if prisoners are typically not even allowed to donate organs? Does the verdict that the donation was “legal” make it also “ethical”? History & Ethics of Anatomy Hildebrandt

Gunther von Hagens Since 2004 evidence has been accumulating that bodies of the executed have been used for the preparation of plastinated human specimens in China. In 1999 Gunther von Hagens, a German plastinator, moved a major part of his operations from Heidelberg, Germany, to Dalian, China. History & Ethics of Anatomy Hildebrandt

Audit 2003: -1 documented Chinese donor -647 adult bodies -3909 body parts -182 fetuses,embryos,neonates -7 bodies with bullet wounds to the head Whereas von Hagens claimed that only donated bodies were being used as whole-body plastinates in his exhibits, he also mentioned the use of unclaimed bodies for other purposes. He stated that he adheres strictly to “the tradition in a given country” and that his body acquisitions always follow the law of the country of origin. An audit of his Dalian Institute in 2003 revealed the presence of only one documented Chinese body donor, whereas the storage area contained 647 intact bodies, 3909 body parts and 182 fetuses, embryos and neonates. Seven bodies showed injuries compatible with an execution, i.e. bullet wounds to the head. Von Hagens, who held his coworker Sui Hongjin responsible for the acquisition of these bodies, had them buried immediately. Von Hagens: - exhibits contain donated bodies exclusively - use of unclaimed bodies for other purposes - body acquisition in strict accordance with the law and “traditions of a given country” History & Ethics of Anatomy Hildebrandt

Whole-body plastinates of unclaimed Chinese bodies, available for a fee from Sui Hongjin, former von Hagen’s co-worker “they are all found by the police and […] nobody claimed them before they were donated to the Medical School” Arnie Geller, President of Premier Exhibitions After his severance from von Hagens, Sui Hongjin established his own plastination laboratory in affiliation with Dalian Medical University. He made whole-body plastinates of unclaimed Chinese bodies available for a fee to Premier Exhibitions, the organizers of “Bodies: the Exhibition,” one of the many new traveling shows of human plastinated specimens. Arnie Geller, president of Premier Exhibitions, said of the bodies: “they are all found by police and […] nobody claimed them before they were donated to the Medical School”. History & Ethics of Anatomy Hildebrandt

In May 2008, a settlement with the attorney general of New York obliged Premier Exhibitions to offer refunds to visitors when it could not prove consent for the use of the bodies in its exhibitions. New York Attorney General Andrew Cuomo commented: "Despite repeated denials, we now know that Premier itself cannot demonstrate the circumstances that led to the death of the individuals. Nor is Premier able to establish that these people consented to their remains being used in this manner." The Premier Exhibitions organizers also pointed out that the bodies were legally obtained by Dalian Medical School, and that they had seen documentation for that, but no signed consent, and had not been able to retain copies of these papers. In addition the official website of the exhibit explained that the bodies were part of a worldwide contingent of “donated or unidentified” bodies. The bodies in this exhibit were young and showed distinctly Asian features, as did many specimens in about ten similar traveling exhibits that mostly originated from new plastination facilities in China. Over the last decades China has developed an active trade with plastinated human specimens, which, according to Sui Hongjin, is due to the multitude of skilled anatomists in this country, but is more likely due to the availability of unclaimed bodies, which may include the bodies of the executed. In July 2006 the Chinese government, concerned about the growing trade with bodies and body parts, issued new regulations that outlawed the purchase or sale of human bodies and restricted the import and export of human specimens, unless used for research. In May 2008, a settlement with the attorney general of New York obliged Premier Exhibitions to offer refunds to visitors when it could not prove consent for the use of the bodies in its exhibitions. New York Attorney General Andrew Cuomo commented: "Despite repeated denials, we now know that Premier itself cannot demonstrate the circumstances that led to the death of the individuals. Nor is Premier able to establish that these people consented to their remains being used in this manner." Again: none of these discriminatory uses of dead human bodies are or were illegal in their context of time and location. However, their ethics are still highly questionable. History & Ethics of Anatomy Hildebrandt

Ethical issues in anatomy (3): Do dead bodies deserve respect? Ambivalence of the dead human body vs. living body Does the dead body have dignity? Sperling’s “human subject “ and its “symbolic existence” The question whether dead bodies deserve respect has been discussed in many venues and over many years. It touches on the ambivalence of the dead versus the living human body as well as on the questions of the dignity of the dead human body. A full account of the philosophical implications of this problem is beyond the scope of this presentation. Opinions range from the concept of the dead human body as a “dead thing” that can be dealt with at will, to the dead human body as an untouchable sacred entity. A comprehensive investigation of so-called “posthumous interests” can be found in Daniel Sperling’s book (see references). His proposal of the recognition of a “symbolic existence” of a “human subject” that persists beyond the end of life seems especially appealing as a guideline in anatomy. Thus, if the living human body is dignified and should be respected, the same applies to the dead human body. History & Ethics of Anatomy Hildebrandt

Winkelmann (anatomist, Berlin, 2003): Death as part of a persons biography Anatomy as an archeology of the living “Anatomical dissection can be seen as the search for traces of the living in the material world [of the body]” Jones and Whitaker (anatomists New Zealand, 2009): “[…] since the dead body was once a living human body, there is a strand between the two, with mutual connections leading in both directions.” Andreas Winkelmann has developed a pragmatic approach to the dead body in anatomy. Winkelmann sees death as part of a person’s biography and the dead body as a continuation of this biography. He interprets anatomy as an “archeology of the living”, in that “Anatomical dissection can be seen as the search for traces of the living in the material world [of the body]” (Winkelmann, 2003). Jones and Whitaker formulate similarly: “[…] since the dead body was once a living human body, there is a strand between the two, with mutual connections leading in both directions.” History & Ethics of Anatomy Hildebrandt

In this sense, donors become our teachers. And while we dissect and find the traces of the living, we also find traces of diseases. Throughout the course, donors will also become our patients. Wilhelm Busch, 19th century Thus, the body donors become teachers of anatomy. As the dissection progresses, they may also reveal pathological findings and thereby become the students’ first patient. Samuel Luke Fildes, 1891: “The doctor” History & Ethics of Anatomy Hildebrandt

[…] It's amazing to think that--as prospective physicians --we may learn more about medicine from one person in death than any living person we may interact with later in our lives. It's a very special gift from someone we will never know. And yet, we may come to know them in ways that no living person ever had before. I'm very excited to begin dissection. This is the statement from another medical student in anticipation of the dissection course. The student voices very clearly this aspect of the donor as teacher: […] It's amazing to think that--as prospective physicians --we may learn more about medicine from one person in death than any living person we may interact with later in our lives. It's a very special gift from someone we will never know. And yet, we may come to know them in ways that no living person ever had before. I'm very excited to begin dissection. Medical student, Class of 2016 History & Ethics of Anatomy Hildebrandt

Ethical issues in anatomy (4): How do dissectors save their humanity? development of a balance between empathy and clinical detachment And finally there is the question as to how one stays human when one does such things as cutting up dead human bodies. One way to approach this question is to think of one’s attitude to donor and patient as a balance between empathy and “clinical detachment”. History & Ethics of Anatomy Hildebrandt

Clinical detachment: “The study of anatomy by dissection requires in its practitioners the effective suspension or suppression of many normal physical and emotional responses to the willful mutilation of the body of another human being.” (Richardson, 1987) “Anatomy is the basis of surgery, it informs the head, guides the hand and familiarizes the heart to a kind of necessary inhumanity.” (William Hunter, ) There are many observations on “clinical detachment” in the literature. It has been called different things by different people. Richardson speaks of an “effective suspension or suppression of many normal physical and emotional responses”. William Hunter, the 18th century Scottish anatomist working in London, called it a “necessary inhumanity”. History & Ethics of Anatomy Hildebrandt abc/R/ramsay/ramsay6.JPG

On the potential effects of anatomical dissection on dissectors: Anatomical dissection produces a “difference between us and other men in the feelings with which we regard the remains of the dead”. This may give rise to “indifference and even a levity of speech and manner, which are abhorrent to the sensibilities of the rest of mankind” and may happen gradually and unawares. If made aware of this it should “teach us to resist whatever may tend, in any degree, to diminish the tenderness, the delicacy, the purity of mind, which are so peculiarly required in the performance of our duties”. John Ware, Dean of the Massachusetts Medical College Introductory Lecture for Medical Students, 1851 John Ware, Dean of the Massachusetts Medical College spoke in his Introductory Lecture for Medical Students, 1851, of an “indifference” which “ diminish[es] the tenderness, the delicacy, the purity of mind” History & Ethics of Anatomy Hildebrandt

- worry about becoming too desensitized (lose the human aspect of medicine by being trained to be tough) Similarly, students worry about becoming “desensitized” and “being trained to be tough” Medical student, Class of 2016 History & Ethics of Anatomy Hildebrandt

I could not answer these questions [of the identity of the body to be dissected] for myself, and certainly not at that moment. I simply connected with the attitude I had learned during my medical service during the Poland campaign. It had occurred to me that one could not work as a physician, if one could not abstract oneself from one’s own emotions during certain situations of suffering and emergency, in order to be able to attend with a level head to that which was factually necessary. Stephan Pfürtner And in 1940 Stephan Pfürtner called it the ability to “abstract oneself from one’s own emotions”. He called this ability as the necessary requirement to be able to help. History & Ethics of Anatomy Hildebrandt

Balance between empathy and clinical detachment
to be a neutral observer and compassionate helper at the same time It is proposed here that, rather than seeing the development of “clinical detachment” as a loss- the loss of sensitivity, or humaneness- it should be recognized as a new skill that is necessary to become a neutral observer. At the same time, the natural empathy that health workers bring to their profession need not at all be diminished or lost by the development of “clinical detachment”, but should be seen as the necessary counterbalance to become a compassionate helper. Thus, the greater the “clinical detachment” becomes, the more empathy has to grow, too. History & Ethics of Anatomy Hildebrandt

“Yet I also believe that the lesson of anatomy is that we do not need to overcome all our emotion or conquer all difficulty in order to be good clinicians. In fact, in light of the important balance that clinical detachment requires, I should perhaps feel encouraged by my inability to always emotionally disengage.” (Christine Montross, 2007) This notion is best expressed by Christine Montross, psychiatrist and author: “Yet I also believe that the lesson of anatomy is that we do not need to overcome all our emotion or conquer all difficulty in order to be good clinicians. In fact, in light of the important balance that clinical detachment requires, I should perhaps feel encouraged by my inability to always emotionally disengage.” (Christine Montross, 2007) History & Ethics of Anatomy Hildebrandt

References: Barilan YM The story of the body and the story of the person: Towards an ethics of representing human bodies and bodyparts. Med Health Care Philos 8:193–205. Blakely R, Harrington JM. (eds.) Bones in the Basement: Postmortem Racism in Nineteenth-Century Medical Training. Washington and London: Smithsonian Institution Press. Dyer GSM, Thorndike MEL Quidne mortui vivos docent? The evolving purpose of human dissection in medical education. Acad Med 75: Goddard S A history of gross anatomy- lessons for the future. Univ of Toronto Med J 80: Halperin, E.C. (2007). The poor, the Black, and the marginalized as the source of cadavers in the United States anatomical education. Clinical Anatomy 20, 489–495. Hildebrandt S Capital Punishment and Anatomy: History and Ethics of an Ongoing Association. Clin Anat 21:5-14 Hunter RH A Short History of Anatomy. London: John Bale, Sons and Danielsson Ltd. Jones, GD; Whitaker, MI Speaking for the dead. The human body in biology and medicine. Second edition. Farnham: Ashgate Park K Secrets of Women: Gender, Generation, and the Origins of Human Dissection. New York: Zone Books. p 15. Richardson R Death, dissection and the destitute. Second edition with a new afterword (2000). Chicago; London: The University of Chicago Press, pp 1-453 Sappol, M. (2002). A Traffic of Dead Bodies. Anatomy and Embodied Social Identity in Nineteenth–Century America. 1st Ed. Princeton, NJ: Princeton University Press. Sperling, Daniel Posthumous interests. Legal and ethical perspectives. Cambridge: Cambrige University Press Spitzer VM, Scherzinger AL Virtual anatomy: An anatomist’s playground. Clin Anat 19:192–203. Spitzer VM, Whitlock DG The Visible Human Dataset: The anatomical platform for human simulation. Anat Rec 253:49–57. Warner, J.H. (2009).Witnessing dissection: Photography, medicine and American culture. In: Warner, J.H., Edmonson, J.M. (Eds). Dissection: Photographs of a Rite of Passage in American Medicine 1880–1930 (pp 7–29). New York, NY: Blast Books. Winkelmann, Andreas Der endgültige abschied vom Leib? Mit ihrer “Faszination des Echten” Definiert die Ausstellung “Körperwelten” auch, was echat ist und was nicht. In: Bogusch, Gottfried; Graf, Renate; Schnalke, Thomas (eds.). Auf Leben und Tod. Beiträge zur Diskussion um di Ausstellung “Köperwelten”. Darmstadt: Steinkopf, p43-53 History & Ethics of Anatomy Hildebrandt

History and Ethics of Anatomical Dissection

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