The Anatomy Lesson of Dr Nicolaes Tulp, Rembrandt
Before we get started, can you spot the error made by Rembrandt in the image above? Back to the task at hand, I decided to write this post after a mini-debate in the anatomy department the day after the memorial service. We were talking about the altruism shown by donors and considering whether we would do the same, I said I was thinking about it, however, I was certain that my family would object. My personal view was that legally this wouldn’t be an issue, after all, if I had given my informed consent, surely my wishes would be respected and my next of kin/family could not overturn my decision, right? Surprisingly, amongst the demonstrators, we couldn’t agree on whether the next of kin could trump a decision made by a donor. As an anatomist and GP, I felt that I wanted clarity on the issue, so I decided to do a little bit of research…
Death and its associated rituals
Anthropological research shows that our ancestors, Homo Naledi were burying their dead as long as 250,000 thousand years ago. Our rituals associated with the death of our loved ones, be they interment or cremation are a part of the human bereavement process. Hence it’s not surprising that throughout history the dead body has been treated in a sacred manner, something not to be defiled or tampered with. Historically the thought of using the deceased for dissection was not only culturally unacceptable but also came with legal penalties. The importance of human dissection begins to gain its advocates in the Renaissance, but even then the issues surrounding the preservation of tissue and ongoing cultural resistance make dissection difficult to accept for society.
A very brief history of human dissection
Human dissection has a long history, the earliest account of systematic human dissection dates back to the 3rd century BC, in ancient Alexandria, Greece. However, after the burning of Alexandra in 389 AD, dissection seems to disappear altogether from Greek Medicine. Dissection fairs no better in the Middle Ages as the church deems it blasphemous. The church’s attitude gradually changes during the Renaissance, Frederick II mandates all physicians and surgeons must dissect a human body once every five years to continue to practice and later the first public dissection was performed by Mondino in 1315. The desire to mimic the human form perfectly in art during the Renaissance, sees artists dissecting to understand the human form better, focusing on the skin and musculature. Leonardo da Vinci delved deeper into the body; much of his discoveries preceded those of Vesalius. Unfortunately, Leonardo did not publish his work.
Over the next few centuries, we see more and more medical schools advocating the study of dissection, the demand gradually outstrips the supply of corpses. To facilitate the need for bodies, we see states increasing the number of crimes punishable by execution and rising number of bodies illegally exhumed by anatomists, or they paid criminals (body snatchers) to obtain corpses for them. Eventually, pressure from physicians and surgeons resulted in changes in legislation throughout Europe, focusing on voluntary donation and banning the use of executed criminals. For a more in-depth account of the history of human dissection, please read Sanjib Kumar Ghosh excellent article.
The law and body donation in England
In England, the Anatomy Act 1832 was passed due to the rising civic concerns regarding the illegal use of corpses. The 1832 act banned the use of executed murderers, before this the Murder Act 1752 permitted the use of executed murderers for dissection. The 1832 Act stated that instead bodies must be volunteered or be unclaimed (from prisons, hospitals or a workhouse) for a minimum of 48 hours. The Act managed to reduce the illegal trade in corpses. However, it also penalised the poor in society, who were unlikely to be able to afford a funeral. Families would donate the body of deceased loved ones to be spared the cost of a burial. The Act was repealed by the 1984 Anatomy Act, this permitted the spouse or family member to overrule the deceased wishes to donate their body. The 1984 Act was amended by the 2004 Human Tissue Act, which gave primacy to the wishes of the deceased and also made the selling of organs illegal.
In England, Wales and Northern Ireland the Human Tissue Authority (HTA) regulates (the removal, storage and use of human tissue) organisations (medical schools in most cases) that collect bodies (interestingly they make a distinction between body, brain and tissues) for the purpose of dissection, medical research and education. The HTA has no jurisdiction in Scotland, the rules surrounding the use of human tissue is governed by The Human Tissue Act 2006 (Scotland) and is the responsibility of Her Majesty’s Inspector of Anatomy for Scotland.
Back to England, the 2004 Human Tissue Act mandates that organisations obtain written and witnessed consent from the donor, this cannot be done retrospectively by relatives after the donor has died (e.g. by way of power of attorney). The process necessitates donors contacting a local medical school directly, from there the bequests department will discuss the process with the potential donor and provide any necessary information. Consent must be informed, written and witnessed for it to be acceptable. Donors must be at least 17 years old to consent to donate their body’s after death, the donor must also draw up a will specifyiing that their body is being donated for “anatomical examination” for their decision to be legally binding. The will must specify the donor’s decision to donate their body (HTA 2004, S.3, subsection (5) a-c). Your body can be donated to any medical school in the UK. However, this usually is only acceptable to medical schools, if donors have arranged to cover the additional costs of transport in cases where the medical school is not local.
Being an organ donor means that after your death your organs can be harvested for the use of transplantation. If however, your organs are not suitable for transplantation, this does not automatically entitle the donor’s body to be used for the purpose of dissection or medical research. The consent for body donation is completely separate. If an individual has agreed to be both an organ donor and has also consented to donate their body, organ donation will trump the latter, in that case, medical schools are unlikely to accept a body from which organs have been surgically removed. However, if the donor’s organs were not suitable for donation, then the body may be accepted by a medical school, so long as valid consent is in place.
What happens when the donor dies?
Donors are advised and encouraged in all cases to inform their families, close friends and GP regarding their wishes. This is partly due to the sensitive nature of the decision, and the potential impact of an unexpected revelation of this kind would have on family and friends immediately after the person’s death. Another reason to discuss the decision with their next of kin is that after the death of the donor, the medical school has to be informed immediately to arrange collection of the body. Medical schools will usually not accept a bequest if they are unable to have the body within five days of the death of the donor. So once the donor has died, it is critical that the next of kin or those with power of attorney inform the medical school as soon as possible. The department will have dedicated staff who will need to collate clinical information from the donor’s GP, nursing staff and or hospital doctors before they can make a decision regarding acceptance. This process may take a couple of days.
The process can be complicated further by weekends and bank holidays. The anatomy departments responsible for bequeathals, usually operate office hours, therefore deaths over long bank holiday weekends or other public holidays can delay or even prevent a donor’s wishes being fulfilled.
Once a body is accepted, the family are asked to register the death and complete any additional paperwork mandated by the Human Tissue Act. The medical school then arranges for undertakers to transfer the body to the anatomy department. Based on guidance from the Human Tissue Act, medical schools arrange an annual memorial service to acknowledge the generous act of body donation and will inform the next of kin if they have agreed to be informed and will provide information on how to obtain the ashes if they so wish.
Issues that arise from the body donation
There are certain reasons where a bequest might not be accepted, this is despite the donor consenting and the family are in agreement. These circumstances include deaths which occur over long public holiday periods as discussed earlier, if there has been a post-mortem examination, a risk of transmissible disease (Tuberculosis, HIV, hepatitis), donors with artificial stomas, large bed sores or skin ulceration and excessive weight or height. Donors who have died of cancer may be accepted depending on the extent of disease. Donors, where there was a history of dementia, may be accepted if there is no evidence to suggest prion disease.
Can a child offer to donate their body? Some of you may be familiar with the famous case of Gillick vs West Norfolk and Wisbech Area Health Authority, the court determined that a child was considered competent to give valid consent to a proposed medical intervention if they had sufficient intelligence and understanding to enable them to fully understand what was involved. Hence under Common law, if a competent child does consent to body donation or other activities regulated by the HTA 2004, that consent carries over into adulthood unless it is withdrawn. In reality, would this even happen?
What happens though when the family’s wish conflicts with the former decision of the donor? The Anatomy Act 1984 act did allow a spouse or family member to overturn the wishes of the deceased. However, the 2004 act gives primacy to the wishes of the donor, in practice though, medical schools rarely go against the wishes of immediate family members, this was anticipated by the House of Lords when the bill was originally debated. In practical terms a surgeon in the case of organ donation or a medical school in terms of a bequest would nearly always side with the family’s wish. Legally the family have no right to override a valid decision made by a donor, so if the donor’s decision is overridden, then in effect the law has been broken, but who will enforce it? To my knowledge, a family’s wish to overturn a donor’s decision has not been challenged in court by a medical school. Interestingly the law (2004 Human Tissue Act) as it stands makes it difficult to legally challenge the donor’s decision (with respect to body donation), mainly because of the time critical nature of body donation. However, if a family did challenge a donor’s decision (where the medical school had not acquiesced to the family’s wishes), the law is clear, but would a decision ignoring the family’s wishes bring the medical/dental school and health professions into disrepute?
- Human Tissue Authority
- Jean, bequeathal secretary, Anatomy department.
- My old school friend Sadia (a solicitor)
- Human Cadaveric dissection, A historical account from ancient Greece to the modern era, Sanjib Ghosh