ética en autopsias (sukol)

7/28/2019 tica en autopsias (Sukol)

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Current Topics

Building on a Tradition of Ethical

Consideration of the Dead

Medical culture espoiises patient interaction based on detached

concem, where emotional attachment to patients is attenuated to

preserve objectivity. The body is viewed as nonliving matter in mo-

tion. Altematively, the cadaver may be considered a gift. To receive

so awesome a gift is an extraordinary privilege; acknowledgment of

this gift affinns our interconnectedness with our co~unity and of-

fers a way to provide for its betterment. Gift exchange establishes a

relationship between donor and recipient, and the absence of an

assigned worth leaves open the cycle of giving and receiving for future

exchanges. Inherent within undertaking a dissection lies an obligation

that the gift not be wasted. Donating one's body for dissection meetsthe criteria for the highest levels of charity as set forth by the 12th-

During my first year of medical school, I spent

many hours in the anatomy laboratory thinking not

only about anatomy but also about the act of dissection

itself. Retraining myself to invade what was previously

sacrosanct, being required to engage in what was so

recently taboo, was frankly, bewildering. How was I to

forget that this cadaver was once a living being long

enough to dismember and explore deep into her tis-

sues? Leon Kass,a physician and ethicist, in discussions .

with first-year medical students immediately after their

first experience in the gross anatomy laboratory, writesthat "almost everyone who spoke acknowledged the

need and desire to respect the mortal remains. . . but

those who were most troubled somehow intuited the

impossibility of doing so. They understood and felt that

they were engaged in something fundamentally disre-

spectful-albeit for a good cause."]

In an attempt to bring into sharper focus the sa-

cred dimension of our task, I composed a brief per-

sonal, Hebrew prayer to recite at the start of each labo-

ratory: Baruch ata adoshem, elokeynu melech haolam, asher

kideysh avodat yadeynu l'avodat'cha hak'dosha[Blessed are

You, Sovereign of the universe, who has consecrated

the work of our hands to Your holy service]. This was

followed by the creation of an Interfaith Service for

Thanks and Respect, which was held one week before

the first gross anatomy laboratory. The relevance of this

preparatory interfaith service is underscored by the fact

that it was attended by nearly one third of my medical

school class, faculty members, nursing students, and

hospital chaplains. The prayer and service were helpful

From the Case Western Reserve University School of Medicine,

Cleveland, OR. Accepted for publication January 25, 1995.

Address correspondence and reprint requests to Roxanne B.

Sukol, MD,3882 Bethany Rd, University Heights, OH 44118.

Copyright 1995 by W.E. Saunders Company

0046-8177/95/2607-0001$5.00/0

century philosopher, physician, and rabbinic scholar Moses Maimon-

ides. Preserving the anonymity of cadavers protects students as well

by enabling them to dissect in an environment that respects the sensi-

tive and difficult nature of the work. Maimonides provides support

for formalizing the anonymous relationship between student and ca-

daver. The anonymous nature of the gift provides enormous latitude

for using the skills thus gained to serve one's patients and to benefit

the common good. HUMPATHOL26:700-705. Copyright 1995 by

W.B. Saunders Company

Key words: cadaver dissection, ethics, Maimonides, medical stu-

dent socialization.

to me but only partially. The fact of my cadaver's for-

merly l~vingstatus continued to trouble me. Initial be-

wilderment was eventually assuaged somewhat by a

sense of the profundity of her gift, the recognition of

which was soon followed by thoughts on the implica-

tions of accepting such a gift.

At the medical school I attend, we are informed

that every body is donated with the consent of its for-

merly living inhabitant. The comments contained in

this article are based on this reality. To dissect a body

and know that consent was never given is a radically

different, and probably more difficult, matter. Freder-

ick Hafferty, whose findings are discussed in more detail

later, writes that all the students he interviewed were

convinced that they had a donated body, although they-

all knew that a significan t percen tage of the bodies used

for dissection at their medical school had not been

donated. Despite the extreme unlikelihood of all the

students having received donated bodies, they were all

nevertheless convinced that theirs was definitely one of

the donated ones.2 Reminding oneself that one's ca-

daver actually chose this fate is one of the ways that

students reassure and protect themselves as they pro-

ceed to dissect.

There is general agreement in the published litera-

ture that the means by which medical students come

to terms with their'cadavers has broad significance for

later interactions with their patients.3-8An article pub-

lished in The Nation provided examples from the au-

thor's own medical training to support her belief that

depersonalizing the cadaver prepares medical students

for later depersonalization of patients. It is an intriguing

concept. How many parallels can be drawn between a


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cadaverand a patient? As student doctors, we conduct

our first procedures on cadavers, dissect out anatomic

structures, use language similar to that heard in the

operating room, wear scrubs, and so on. Inasmuch as

medical culture espouses patient interaction based on

a model of detached concern, where emotional attach-

ment to patients must be attenuated at the risk of com-

promisingone's objectivity,9 medical students begin im-

mediately to adopt this model in the gross anatomy

laboratory.

In his ground-breaking study Into the Valley: Death

and the Socialization of Medical Students, Frederick Haf-

fertyobserved and participated with first-year students

at an urban medical school throughout the course of

theiryear-long experience in the anatomy laboratory.

In extensive interviews, Hafferty heard students de-

scribethe dissection experience as a good opportunity

forlearning to detach themselves, with the recognition

that this skill would also prove useful later in the hospi-

tal. In actuality, the students' ability to detach them-

selveswaxedand waned through the year based primar-

ily on the body part being dissected, with the most

difficultbeing the head and neck, hands, and genitalia.

Issuesof mortality play an important part in objecti-

fyingthe cadaver. Hafferty devotes an entire chapter to

the "ambiguous man," so called because of what he

refers to as the cadaver's ambiguous state as partially

human yetpartially not. Labeling the cadaver clearly as

"not-me" obfuscates identification with the cadaver

and thus consideration of one's own mortality. Yet the

cadavercannot help but display its humanity to all who

encounter it, and students are not always successful at

maintaining their distance.According to Hafferty, only a few students consis-

tentlyperceived their cadavers as biological specimens,

without regard for their formerly living status. Several

students whom he interviewed expressed uneasiness

withthe fact of other students' successful detachment,

despite concurrent and extensive attempts to emulate

them. Thus, it appears that although there was

agreement about the importance of maintaining one's

objectivity,these first-year students were still not con-

vincedthat it should be gained at the expense of com-

plete detachment.

Kassobserves that although nonmedical personnelare expected to experience a strong aversion to the

cadaver, this reaction is considered inappropriate and

unreasonable for medical students, for whom the cor-

rectposture must be one based on a scientific perspec-

tivethat regards the living body as nonliving matter in

motion. Although at some previous time it would have

been perfectly reasonable to feel queasy in an anatomy

laboratory, one is expected to undergo a transforma-

tion on entering medical school. Fox9 extends the de-

velopmentof detached concern to include the impacts

ofattending one's first autopsy as a second-year medical

student and performing procedures on live animals.

Physicians-in-training become part of a adaptation pro-

cessthrough which they learn in a stepwise fashion to

suppress emotional responses, and dissociate them-

selves more and more efficiently from emotionally sig-

nificant aspects of their work.

As part of the interviews, Hafferty' asked students

if they would consider donating their own bodies for

dissection. Of the 99 total students, 82 said no, 11 said

yes, and 6 were undecided. He reports that all aban-

doned the customary calm they had maintained

through their interviews, and responses became abrupt,

tension laden, and filled with emotion. Of those who

said yes, the primary reason given was their perceived

academic importance of dissection. Nine of these 11

had high attendance records in anatomy laboratory,

and 10 had a primary definition of the cadaver as a

formerly living human being. They considered this per-

spective an important means of fighting against the de-

tachment inherent in the laboratory experience. Haf-

ferty concludes that good adjustment to the laboratory

is a three-part process that requires recognition of the

cadaver as a generalized other, acceptance of it as a

personal symbol, and successful adaptation to the ten-

sion endemic to these perspectives.Thoughts about the cadaver-as-self obviously in-

volved recognition of the self as mortal. The anatomy

laboratory is where medical students begin to construct

an image of the physician as fundamentally different

from laypersons. Medical students learn to expect and

count on differences in knowledge and experience be-

tween physicians and laypersons. As mentioned earlier,

it was important for students to imagine that their ca-

daver was donated. But did these donors truly give a

fully informed consent? Hafferty suggests that the re-

fusal to entertain the prospect of donating one's own

body may imply a belief that the formerly living person

did not fully understand what would happen and, there-

fore, did not really give informed consent. VancelO

notes that the reluctance of physicians to consent to

autopsies of themselves or their family members illus-

trates an inherent conflict between two rationally held

values: the goal of the medical profession to be self-

critical as weighed against cultural beliefs regarding ap-

propriate treatment of the dead.

Hafferty found that instructors' teaching styles had

a serious impact on student attendance in gross anat-

omy. He showed that students assigned to groups whose

instructor acknowledged the emotional significance of

dissection continued to attend laboratory in unusuallyhigh numbers for the duration of the course. This ac-

knowledgment was generally brief and consisted simply

of the fact that it was all right to feel uncomfortable

under the circumstances. In contrast, students assigned

to groups whose instructor was particularly insensitive

(eg, leaning on a cadaver's face at orientation, charac-

terizing students who expressed discomfort as weak or

even unsuitable), were much more likely to begin miss-

ing sessions and then to cease attending altogether.

Students assigned to instructors who were neither sensi-

tive nor particularly insensitive, but who nevertheless

did not acknowledge the potentially distressing nature

of dissection also had an attrition rate much higher

than that of students whose instructors acknowledged

the legitimacy of any distress they might feel. One stu-


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dent stated that although laboratory orientation might

have provided a valuable opportunity for faculty mem-

bers to emphasize physicians as sensitive and caring, it

was instead an alienating event. The dramatic differ-

ences illustrated by these surprising findings should be

of interest to all medical educators.

What makes it so difficult to dissect a dead human

being? What is it about dissection that seems like such

a violation? To the lay person, the answers seem so

obvious as to make such questions absurd. To the medi-

cal community, however, any obvious answers to these

questions have been long forgotten. If for this reason

alone, asking ourselves these questions once again is

worthwhile.

Kass1provides some insight in his discussions con-

cerning the sense of responsibility that human beings

feel toward their deceased, those to whom they are con-

nected by ties of kinship. He explains that an individu-al's perception of one's place in the line ofgenerations

is crucial to the development and preservation of soci-

ety and culture, to the fabric of that individual's world.

To disrupt this chain is to disrupt a person's grounding

in the world, the internal systems by which one orga-

nizes one's thoughts, perceives right and wrong, and

perhaps maintains one's sanity.

All cultures have sacred ceremonies and customs

concerning the treatment of their dead, with burial and

cremation being those most familiar in Western society.

Following the death of a loved one, the rituals of our

community often become of heightened importance,

and we perform them faithfully. We work to ensure thatthe body of the recently deceased is adequately cared

for, and not treated inappropriately. The purpose of

these practices, particularly the last, is not simply to

facilitate entry into the cycle of grief and healing but,

as Kass1notes, to maintain one's place in the very cycle

of humanity. Words from the Order of Christian Funerals

express this so clearly, "Though separated from the

living, the dead are still at one with the community of

believers on earth.. . . The community. . . recognizes

the spiritual bond that still exists between the living andthe dead." 11

Another example concerns the transplantation of

organs from cadaver donor sources. In contrast to other

parts of the world, this practice has not been used widely

in Japan. Feldman 12 asserts that the reasons stem in

part from Shinto-based beliefs that the welfare of the

living is dependent on paying appropriate homage to

the dead. The human body and its meaning hold uni-

versal truths for those to whom it is entrusted.

Abraham Joshua Heschel, aJewish ethicist, philoso-

pher, and theologian, explains that the universal truths

of the human body transcend the truths of those to

whom the body is entrusted. Heschel13 invokes the bibli-

cal story of creation in his reflections on the holiness

of humanity. According to Genesis, human beings were

created in the image of God, and "the image is not in

human beings, it is human beings." The sparing use of

the image of God throughout the Hebrew Bible "re-

minds us that the body of man, not only his soul, is

endowed with divine dignity."13

Heschel emphasizes the partnership between Godand human beings. He describes the vital needs of the

body and soul as being of divine concern, and explains

this as evidence that human life is indeed holy. He

writes that although the divine likeness of the human

form is an idea familiar to many religions, 'Judaism

contributed the tremerrdous implication of that idea:

the metaphysical dignity of man, the divine pre-

ciousness of human life. Man is not valued in physical

terms; his value is infinite."13 Despite the fact that com-

mon sense would tell us two human beings are more

than one, Heschel reminds us that Jewish tradition

teaches that to cause one single soul to perish is as if

one had caused the destruction of the entire world; tosave one single soul is as though one had saved the

entire world. Each individual human being is precious

and sanctified.

Heschel is concerned with the routine activities of

everyday life. Although they may seem ordinary, each

of them possesses intrinsic sacred value as an event in

the unfolding, or creation, of the universe. We are

granted the ability to acknowledge the sacredness of

such activities by identifying them in time, thereby sanc-

tifYing the concept of time as well. What separates a

common activity, such as eating, from its sacred dimen-

sion is the simple act of acknowledgment. To Heschel,

reciting a blessing when one eats, awakens, washes one'shands, or even dissects acknowledges the sacred dimen-

sion of that activity and elevates it to its valid place in

creation.

Reciting a blessing before the beginning of each

dissection laboratory has given me a way to acknowl-

edge not only that my cadaver contains mysteries I will

never understand but that we are both part ofthe same

universe.

Martin Buber14describes twopossible kinds ofreIa-

tionships in the world: I-Thou and I-It. One enters into

an I-Thou relationship with one's entire self. "I" is not

distinct from "Thou," and the resultant I and Thou

form a single entity that is defined as I-Thou. Con-

versely, where "I" becomes distinct unto itself, the rela-

tionship is termed I-It, an association between two sepa-

rate entities. The subject of the I-Thou relationship is

the relationship itself; no object exists within the rela-

tionship. The subject ofthe I-It relationship is "I," who

perceives "It" as the object.

The cadaver as biological specimen is an object

whose purpose is defined entirely by the medical

school's perception of its purpose. The medical student

becomes "I" and the cadaver "It." This perspective is


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not entirely disadvantageous, because the student who

is unable to separate sufficiently from identification

withthe cadaver will be unable to dissect at all. I-Thou

identification with family members and friends may be

whatmakes contemplation of their dissection, even by

others, so gruesome.

The goal is not to aspire to achieve an I-Thou rela-

, tionshipwith one's cadaver. Rather, it is to appreciatethat the cadaver itself was once a human being who,

independently, had the capacity to participate in his or

her own I-Thou relationships. The person who inhab-

ited this body assuredly had significant relationships

with others; memories of this person and his or her

- influences, for better or worse, are now carried by the

'people who survived and for whom his or her memory

ismeaningful.

Cadaver as Gift

Thomas Murray,15 discussing blood donation in

the United States, declares that gifts of the body areaffirmations of the need to define our community and

ourinterconnectedness with its members. Giving some-

thing of oneself, here an actual part of one's body,

defines the greater community of which one is a part,

confirmsits importance, and offers the donor a way to

provide for its betterment.

Last year, the New York Times Magazine featured a

story about a man trying to fulfill his father's dying

wishto donate his body to science.16 An appalled and

bereavedson was directed to begin his inquiry into the

logisticsof such a task with the attending physician.

The physician, once he understood the basis for the

man'srequest, reassured him that his actions were' 'very

honorable ... no ... very noble" and that his father

was making "a truly generous gift." The physician's

wordsled the man to consider that there might be at

least a couple of "true healers" among the roomful

of "wisecracking medical students ... making snide

witticisms" who would one day dissect his father'sbody.16

Donating one's body for dissection meets the crite-

ria for the highest levels of charity as set forth and

ranked by Moses Maimonides.17 Maimonides, a 12th-

century Spanish physician, philosopher, and rabbinic

scholar,believed that aiding a person to become self-supporting (ie, to earn a living) was the highest level

ofcharity. He further stated that charity from one indi-

vidualto another, the identity of each unknown to the

other, was the second highest level of charity. Further

down on the list was the case where the donor and

recipient each knew the identity of the other, and fur-

thest down was the case where the donor gave grudg-

ingly.

Donating one's body for dissection provides its re-

cipient(s) with not only the opportunity to learn a par-

ticular body of knowledge and set of skills, but also, it

turns out, the ability to earn .a livelihood. Thus, the

donated body becomes a means by which an anony-

mous donor assists another individual to become self-

supporting. Maimonides considered this to be the high-

est level of charity.

Donors of bodies and their medical student recipi-

ents are unknown to one another, and arrangements

for transfer of bodies to medical schools usually are

made by the schools themselves. At the medical school

I attend, and at all others as far as I know, one never

knows the identity of one's cadaver. To prevent such

an eventuality, we are requested specifically to notify

the faculty if we know of anyone who has donated abody within the past 2 years. Of course, donors will

never know the identity of those who receive their bod-

ies, not least because, in many cases, the students have

not yet even been accepted to the school. The doubly

anonymous nature of these donations meets the criteria

for Maimonides's second highest level of charity.

Concern about having to dissect someone you

know is nothing new. Among the various kinds of maca-

bre jokes traditionally told by medical students, Haf-

ferty18 includes the category of "cadaver as r elative/

friend." In the past, these jokes have always served as

a socially sanctioned (ie, by medical school culture)means for expression of the various kinds of anxiety

engendered by dissection. Preserving the anonymity of

cadavers protects students as well by enabling them to

dissect in an environment that respects the already sen-

sitive and difficult nature of this work. Maimonides pro-

vides support for formalizing the anonymous relation-

ship between the student and an autopsy or an

anatomic dissection.

The cadaver is a profound gift made b y its donor

(ie, the formerly living person) to students of medicine.

Lewis Hydel9 distinguishes between gifts and commodi-

ties in The Gift: Imagination and t he Erotic Life of Property.

A gift has intrinsic value; a commodity has monetary

worth. Commodities are bought and sold in the market-

place as part of an interaction with limited boundaries,

whereas gifts are not limited in the same sense. Medical

schools do not purchase ca.davers, nor are organs sold

to hospitals. In recent years, hastened by an understand-

ing of how the purchase of blood products was contrib-

uting to the spread of the acquired immunodeficiency

syndrome (AIDS) and hepatitis, we have seen blood

banking converted almost entirely to a voluntary sys-tem.15,20

The exchange of a gift establishes a relationship

between its d onor and recipient, and the absence of

an assigned worth benefits those who participate in its

exchange by leaving open the cycle of giving and receiv-

ing for future exchanges. Discussing the system of gift

exchange engaged in by the Trobriand Islanders of Me1-

anesia, Marcel Mauss explains that the act of receiving

commits oneself to the partnershw, and failure to re-

turn gifts means a loss of dignity. For a modern-day

example, if you need to prune a tree in your yard,

you can borrow a saw from your neighbor, or you can

purchase one at a hardware store. The first kind of

interaction, borrowing the neighbor's saw, engenders

a relationship with certain associated obligations,

~hereas purchasing one does not.


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Obligations of the Recipient

Murray writes that paradox is characteristic ofgifts:

"Their motivation often seems both selfish and un-

selfish. They are given under conditions of freedom,

yet are powerfully binding. They must be given gener-

ously and without promise of return, yet they must be

reciprocated."22 There is responsibility inherent in ac-

cepting a gift; the act of receiving commits one to the

relationship.

- Along with the gift comes responsibility, and what

one does, and intends to do, with one's cadaver and the

knowledge gained from it, constitute the basis for that

responsibility. The issue of purpose, therefore, is an inte-

gral element of the obligation. In an immediate sense,

the individual who accepts a cadaver for dissection makes

a personal commitment to take advantage of that gift,

to use the opportunity to learn as much as possible about

the human body. To accept a cadaver in the spirit in

which it is given, it is imperative that the gift not be

wasted. As Vance23explains, performing autopsy (or dis-

section) in the pursuit of knowledge is a direct extension

of the physician's commitment to be competent. Theobscenity would be to waste the opportunity to make the

dead have meaning for the living.

The obligations of the individual who undertakes

performing a human dissection are threefold: to one-

self (ie, the dissector), to one's cadaver (ie, the donor),

and to one's community. The first obligation is to one-

selfand concerns acknowledgment. To receive such an

awesome gift is indeed an extraordinary privilege. This

simple truth is the essence of the obligation.

One's second obligation, to the cadaver/donor,

concerns the issue of respect. Acknowledging the awe-

some nature of this individual's gift, as described pre-

viously, necessarily directs one toward respect. Clearlywe can never know a donor's particular motivation for

having made a gift. Vetwe can express our appreciation

and gratitude for this final behest in literally an infinite

number of ways-in silence or aloud, in solitude or

company, in word or deed.

One's third obligation, to the community, is re-

lated to the connection made by Murrayl5 between gifts

of the body and affirmation of the community. Having

received an education and livelihood in part from the

cadaver, one may then consider how best to use the

skills thus gained to serve one's patients, to benefit the

common good, and to reciprocate this gift from the

community. Fortunately, as infinite as the means forexpressing appreciation to the cadaver, so too are those

for expressing appreciation to the community. Th~

anonymous nature of the gift provides enormous latI-

tude for doing so, and our careers as professionals and

community members will offer numerous and varied

opportunities to return the favor.

Standing in anatomy laboratory, I cannot help but

be moved by the human body that lies before me. Sev-

eral of my classmates have told me that they stop dis-

secting relatively frequently to remind themselves that

their cadavers willingly donated their bodies. Dissecting

is a difficult task. At the end of the school year, many

medical schools hold a memorial service for cadavers'

family members and medical students to commemorate

the final disposition of the remains of the dissected

bodies. A member of the class ahead of mine told me

how surprised she was initially to see family memberscrying at last year's memorial service because she had

almost forgotten there was anything to cry about. They

are a powerful reminder that we dissect not some model

biological specimens, but mothers, fathers, sister~,

brothers, friends, teachers, caretakers, lovers, mUSI-

cians, scientists, comedians, and philosophers.

The cadaver has much to teach us, and those who

shield themselves from its humanity also shield them-

selves from some of the most important lessons of all.

The obligation may at times seem obscure, but acknowl-

edging the gift and all that it entails has broad implica-

tions for medical education and practice. The profun-

dity of the gift merits such thoughtful consideration.

Acknowledgment. I would like to acknowledge the guid-

ance of Dr Stephen Post at the Center for Biomedical Ethics

at Case Western Reserve University.

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ética en autopsias (sukol)

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