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History and Ethics of Anatomical Dissection

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Title: History and Ethics of Anatomical Dissection


1
History and Ethics of Anatomical Dissection
  • Sabine Hildebrandt, MD
  • Boston Childrens Hospital/Harvard Medical School
  • Sabine.Hildebrandt_at_childrens.harvard.edu

2

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?
3
  • Anatomy
  • 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)

Andreas Vesalius (1514-1564)?De Humani Corporis
Fabrica Libri Septem ?(Basileae ex officina
Ioannis Oporini, 1543)
4
Vesalius Juan Valverde Hans
von Gersdorf 16th century anatomists ana-temnei
n Greek for to cut apart, dismemberment
5
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 persons dead body.
6
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.
Medical student, Class of 2016
7
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?
Hadnt 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?
Stephan Pfürtner,1922-2012, theologian and
medical student in Breslau/Wroçlaw 1940
8
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

9
  • 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

10
Sources of bodies for anatomical dissection in
history
  • period - bodies of executed criminals
  • - bodies robbed from graves

11
First human dissections in Alexandria, around 300
BC
Herophilus of Chalcedon, 325-260 BCE
Erasistratus of Chios, 304-250 BCE
upload.wikimedia.org/ wikipedia/en/thumb/6/66/..
http//archives.cnn.com/2000/books/news/08/09/egyp
t.library.reut/map.egypt.alexandria.jpg
www.health.gov.mt/.../ issue1/ipc0012205.jpgwww.cu
lture.gouv.fr/ ENSBA/Icones/Guillemot.gif
12
  • Galen?(131-200 CE)
  • Roman physician
  • wrote on all aspects of medicine, including
    anatomy
  • no human dissection

opioids.com/ opium/galen.jpg
13
Mondino de Luzzi (1276-1326 CE)
Public dissections Bologna, Italy
medinfo.ufl.edu/other/ histmed/rarey/images/14.jpg
14
City of Padua, Italy 1539 bodies of the
executed for Andreas Vesalius (1514-1564
CE) First author of a comprehensive and
systematic view of human anatomy, revolutionized
the field.
http//www.objectivemedicine.org/images/Vesalius.j
pg
15
The bodies of the executed were the first legally
assigned source of bodies for anatomical
dissection
Scotland 1506
England 1540
Prague 1600
Salerno 1241
Giessen 1676
Padua 1539
Florence 1387
16
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)
www.library.northwestern.edu/.../images/1.70.jpg
17
Sources of bodies for anatomical dissection in
history
2. period unclaimed bodies, end of 17th century
and after
18
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
www.medizin.uni-halle.de/.../ 561/st_Anatomie.jpg
www.wga.hu/art/ m/meytens/2maria_t.jpg
19
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.
archive.student.bmj.com/.../ life/images/04.jpg
20
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.


21
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 1933-1945 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
22
Results from an archeological excavation of the
dissection rooms at the Georgia Medical
College Skeletal remains from dissections
1840-1880 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
23
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.
24
  • German Anatomy during National Socialism,
    1933-1945
  • 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

Justifizierter executed man, Metzenbauer,
1942
25
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
26
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
27
National Library of Medicines Visible Human
Project (male)
The visible human data set an image resource
for anatomical visualization -CT/MRI,
cryosections
28

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
anatomists sic centuries ago, would be
teaching us once again, perhaps in some way
repaying society for their crimes. Spitzer
and Whitlock, 1998
29
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
30
Gunther von Hagens
31
Audit 2003 -1 documented Chinese donor -647
adult bodies -3909 body parts -182
fetuses,embryos,neonates -7 bodies with bullet
wounds to the head
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
32
Whole-body plastinates of unclaimed Chinese
bodies, available for a fee from Sui Hongjin,
former von Hagens 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
33
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."
34
  • 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?
  • Sperlings human subject and its symbolic
    existence

35
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.
36
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
Samuel Luke Fildes, 1891 The doctor
37
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
38
Ethical issues in anatomy (4)
  • How do dissectors save their humanity?
  • development of a balance between empathy and
  • clinical detachment

39
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,
1718-1783)
www.join2day.com/ abc/R/ramsay/ramsay6.JPG
40
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
41
- worry about becoming too desensitized (lose
the human aspect of medicine by being trained to
be tough)
Medical student, Class of 2016
42
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
ones 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
43
  • Balance between empathy and clinical
    detachment
  • to be a neutral observer and
  • compassionate helper at the same time

44
  • 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)

45
References Barilan YM. 2005. The story of the
body and the story of the person Towards an
ethics of representing human bodies and
bodyparts. Med Health Care Philos
8193205. Blakely R, Harrington JM. (eds.) 1997.
Bones in the Basement Postmortem Racism in
Nineteenth-Century Medical Training. Washington
and London Smithsonian Institution Press. Dyer
GSM, Thorndike MEL. 2000. Quidne mortui vivos
docent? The evolving purpose of human dissection
in medical education. Acad Med 75969-979 Goddard
S. 2003. A history of gross anatomy- lessons for
the future. Univ of Toronto Med J
80145-147 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,
489495. Hildebrandt S. 2008. Capital Punishment
and Anatomy History and Ethics of an Ongoing
Association. Clin Anat 215-14 Hunter RH. 1931.
A Short History of Anatomy. London John Bale,
Sons and Danielsson Ltd. Jones, GD Whitaker,
MI.2009. Speaking for the dead. The human body in
biology and medicine. Second edition. Farnham
Ashgate Park K. 2006. Secrets of Women Gender,
Generation, and the Origins of Human Dissection.
New York Zone Books. p 15. Richardson R. 1987.
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
NineteenthCentury America. 1st Ed. Princeton,
NJ Princeton University Press. Sperling, Daniel.
2008. Posthumous interests. Legal and ethical
perspectives. Cambridge Cambrige University
Press Spitzer VM, Scherzinger AL. 2006. Virtual
anatomy An anatomists playground. Clin Anat
19192203. Spitzer VM, Whitlock DG. 1998. The
Visible Human Dataset The anatomical platform
for human simulation. Anat Rec
2534957. 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 18801930 (pp 729). New York,
NY Blast Books. Winkelmann, Andreas. 2003. 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
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