medical education the legal and ethical framework ...eurjanat.com/data/pdf/eja.08010001.pdf · 8-...

SUMMARY

Discussions at the inaugural meeting of aTrans-European Pedagogic Research Group forAnatomical Sciences highlighted the fact thatthere exist considerable variations in the legaland ethical frameworks throughout Europeconcerning body bequests for anatomicalexamination. Such differences appear to reflectcultural and religious variations as well as dif-

ferent legal and constitutional frameworks. Forexample, there are different views concerningthe “ownership” of cadavers and concerningthe need (perceived by different societies andnational politicians) for legislation specificallyrelated to anatomical dissection. Furthermore,there are different views concerning the accept-ability of using unclaimed bodies that have notgiven informed consent. Given that in Europe

Eur J Anat, 12 (1): 1-24 (2008)

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The legal and ethical frameworkgoverning Body Donation in Europe - A

review of current practice andrecommendations for good practice

S. McHanwell1, E. Brenner2, A.R.M. Chirculescu3, Jan Drukker4, H. vanMameren4, G. Mazzotti5, D. Pais6, F. Paulsen7, O. Plaisant8, Maître M.

Caillaud8, E. Laforêt8, B.M. Riederer9, J.R. Sañudo10, J.L. Bueno-López11, F.Doñate-Oliver11, P. Sprumont12, G. Teofilovski-Parapid13 and B.J. Moxham14

1- Oral Biology, 5th Floor, School of Dental Sciences, Dental School, Framlington Place, Newcastle upon Tyne,NE2 4BW, UK2- Department of Anatomy, Histology and Embryology, Division for Clinical Functional Anatomy, Innsbruck Medi-cal University, Müllerstrasse 59, A-6020 Innsbruck, Austria3- Department of Anatomy and Embryology, Faculty of Medicine, C Davila University, Bucharest, Romania4- Department of Anatomy and Embryology, University of Maastricht, PO Box 616, Maastricht, 6200 MD, TheNetherlands5- Dipartimento di Scienze Anatomiche Umane, Facoltà di Medicina e Chirurgia, Università di Bologna, via Irne-rio, 48, 40126 Bologna, Italy6- Departamento de Deontologica, Bioética e Direito Médico, Faculdade de Ciêncies Médicas da UniversidadeNova de Lisboa, Campo dos Mártires da Pátria, 130 1169-056 Lisboa, Portugal7- Department of Anatomy and Cell Biology, Martin-Luther-University, Halle-Wittenberg Große Steinstraase, 52,06097 Halle (Saale)/Germany8- Université René Descartes Paris V, Faculté de Médecine, Laboratoire d’anatomie, 45, Rue Saints Pères, 75006Paris, France9- Département de Biologie Cellulaire de Morphologie, Université Lausanne, rue du Bugnon, 1005 Lausanne,Suisse10- Departamento de Anatomía y Embriología Humana I, Facultad de Medicina, Universidad Complutense, Ciu-dad Universitaria s/n, 28040-Madrid, Spain11- Departamento de Neurociencias, Facultad de Medicina y Odontología, Universidad del País Vasco, 46040Leioa, Spain12- Unit of Anatomy, Department of Medicine, University of Fribourg, route Albert Gockel 1, CH-1700 Fribourg,Switzerland 13- Institute of Anatomy, School of Medicine at University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia14- School of Biosciences, Cardiff University, Cardiff CF10 3AP, UK

Correspondence to:Prof. Stephen McHanwell. Oral Biology, 5th Floor, School of Dental Sciences, DentalSchool, Framlington Place, Newcastle upon Tyne, NE2 4BW, UK. Tel.: +44 191 2226652. E-mail: [email protected]

Submitted: July 10, 2007Accepted: November 30, 2007

MEDICAL EDUCATION

there have been a series of controversialanatomical exhibitions and also a public (tele-vised) dissection/autopsy, and given that thecommercial sale or transport of anatomicalmaterial across national boundaries is stronglydebated, it would seem appropriate to “har-monise” the situation (at least in the EuropeanUnion). This paper summarises the legal situ-ation in a variety of European countries andsuggests examples of good practice. In particu-lar, it recommends that all countries shouldadopt clear legal frameworks to regulate theacceptance of donations for medical educationand research. It stresses the need for informedconsent, with donors being given clear infor-mation upon which to base their decision,intentions to bequest being made by the donorbefore death and encourages donors to discusstheir wishes to bequeath with relatives prior todeath. Departments are encouraged, wherethey feel it appropriate, to hold Services ofThanksgiving and Commemoration for thosewho have donated their bodies. Finally, thereneeds to be legislation to regulate transport ofbodies or body parts across national bordersand a discouragement of any moves towardscommercialisation in relation to bequests.

Key words: Body donation – European Com-munity – Legal and ethical aspects

INTRODUCTION

Following discussions by the EuropeanFederation for Experimental Morphology(EFEM), it was agreed that there was a need todevelop pedagogic research for the anatomicalsciences to encourage quantitative investiga-tions that had the rigour of laboratory-basedstudies. To this end, a Trans-European Peda-gogic Research Group for the anatomical sci-ences was set up under the initial leadership ofthe immediate Past President of the EFEM,Professor Bernard Moxham. This group, con-sisting of teaching enthusiasts that spannedthe anatomical associations within Europe,had its first meeting in Paris in March 2005.This inaugural meeting comprised talks relat-ing to the legal and ethical positions relatingto body bequests for anatomical examinationin various European countries. The impetusfor this came from the recent exhibitions ofanatomical material by von Hagens and asso-ciates (Morris-Kay, 2002; Barilan, 2006) andfrom new legislation being enacted (or consid-

ered) in various parts of Europe as a result ofpublic concern regarding the retention ofparts/organs for pathological and/or anatomi-cal purposes. The group recognised that whilesome information concerning the legal frame-work and practical concerns surrounding bodybequests has been published in relation tosome countries, (Spanish Anatomical Society,1996; Torres and Couessurel, 2002) informa-tion about the situation Europe-wide wasfragmentary. Reviews of some of the ethicalissues surrounding body donation have beenpublished recently by Jones (2002) and Bari-lan (2006). The present paper provides a sum-mary of the talks summarising the legalframeworks for body bequests in countries ofthe participants at this meeting and providesexamples of good practice recognised by theGroup following further discussion at themeeting.

PERSPECTIVE FROM AUSTRIA(PROFESSOR E. BRENNER)

Austria is a federal state with frameworksof national and federal law. Consequently,both frameworks are seen to operate in rela-tion to the regulation of bequests of bodies foranatomical education and research. First thenational legal framework will be described. InAustria, the cadaver after death is regarded asan entity and it is inherited upon death by theprincipal heir. According to Austrian nationallaw, scientific institutions (in general Insti-tutes, Departments or Divisions of MedicalUniversities) are entitled to receive the bodyafter death mainly by means of a specific lega-cy, which is a special form of last will and tes-tament. Also the principal heir can offer thebody to appropriate scientific institutions;nevertheless, these offers are rejected due tothe policy of ethics, which demands informedconsent. Other laws, which regulate the dis-posal of cadavers upon decease, include regu-lations concerning the disposal of cadavers ofthose who have died of notifiable infectiousdiseases, other post-mortem disposals, such aswhere to and how a cadaver may be transport-ed, and relate to international treaties con-cerning the transportation issues.

It is federal state law that controls all pro-cedures and processes that must take place fol-lowing decease. These laws cover theexamination of the cadaver by a Parish Physi-cian, the issuing of a death certificate and the

S. McHanwell, E. Brenner, A.R.M. Chirculescu, Jan Drukker, H. van Mameren, G. Mazzotti, D. Pais, F. Paulsen, O. Plaisant, Maître M. Caillaud, E. Laforêt, B.M. Riederer, J.R. Sañudo, J.L. Bueno-López, F. Doñate-Oliver, P. Sprumont, G. Teofilovski-Parapid and B.J. Moxham

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arrangement for a funeral (when and where).However, there are nine Federal States andconsequently nine separate sets of Laws regu-lating the details of these processes. It is notpossible, within the confines of this short arti-cle, to summarise details of the different laws.Instead an example of how these Laws operatewill be given by describing the proceduresthat occur in the State in which the author`sown Department is located, the Tyrol.

Under Tyrolean Parish Sanitary Law, anyunclaimed cadavers “have to be handed over tothe Anatomischen Institut der UniversitätInnsbruck, now the Division of Clinical Func-tional Anatomy.” All the costs of recovery andsubsequent transport to Innsbruck are to bemet by the department. Although this is cur-rent law, the division in general rejects thesecadavers, for two reasons. The first reason isour ethical policy of informed consent. Theother reason is the time-factor, as it can takeseveral days to find out that there are no livingrelatives who might claim the body (afterwhich time cadaver preservation is difficult).However, federal law also permits the dona-tions of cadavers to the Institute via a specialwill or legacy. In Tyrolean law, all such lega-cies are regarded as originating from the per-son in life concerning their wish as to howtheir cadaver can be used after death and socannot be overridden by relatives. Conse-quently, such a bequest can be cancelled at anytime by the donor. Donations also can berejected by the legatee who is under no obli-gation to provide any reason. Nevertheless,the division is aware of the fact that some-times relatives do not inform the division ofthe death of a person who has made such a lastwill.

The process of making such a bequest usu-ally begins with an interested person makingan initial contact with the division. Inresponse to any such request, the division willsend out an information leaflet accompaniedby two copies of a legacy form with the fol-lowing wording: The Division of clinical-func-tional Anatomy of the Department of Anatomy,Histology and Embryology at Innsbruck MedicalUniversity is very glad about the fact that you havedecided to help the medical sciences with your bodyafter your death. By this way you help with a goodeducation of young doctors and make new advancesfor our science possible.

We are striving to hold the formalities as low aspossible and send you for this purpose two forms(bequests). Please sign both forms. One of the forms

please send back to us, the other one you should storewith your papers. The enclosed cards should be car-ried along by you constantly. Furthermore it wouldbe expedient if you inform your family doctor of yourdisposal.

Just in case we would like to inform you that theDivision will carry the expenses of a possible over-pass to Innsbruck of course. In the same manner, wecarry the expenses for a simple, quiet burial in Inns-bruck at the Pradler graveyard (honorary-burial-facilities of the Division). If your relatives wouldlike to take part in this funeral, it will be possible,when they take over the additional costs.

If any obscurities should exist, do not hesitate tocontact the Division.

The legacy form is an important document.Its text asks the potential donor to confirmthat he or she is willing to leave their cadaverto the division for the purposes of teachingand research, that the relatives or his or herphysician will inform the division immediate-ly upon their decease, that he or she hasreceived the information leaflet and agreedwith the procedures set out for transfer to thedepartment and subsequent disposal, and thatthe relatives agree to the donor’s wishes. Thepotential donor then returns one signed copyof the legacy to the division and retains a copyfor themselves. For a bequest to be received,donors must be registered with the division.

Once the division is notified of the death ofa legatee, a physician on duty will decidewhether it is possible to accept the bequest orwhether it should be rejected. Rejection of thebequest can be made without providing rea-sons. Nevertheless, the main reasons are: amajor delay in information being received (i.e.more than 72 hours after death), severalknown infectious diseases, or major destruc-tion of the cadaver due to accidents. Once thedecision to accept the bequest has been taken,the physician on duty will make the necessaryarrangements for the transfer of the body tothe division. Should there be any difficulty inarriving at a decision, for example if a deathoccurs abroad, then the physician on duty willrefer the matter to the Director who will takethe final decision. Once the cadaver is receivedinto the division, the physician on dutyensures that the necessary registration proce-dures are carried out, checks the accompany-ing papers and inspects the cadaver. Oncethese initial administrative procedures arecomplete then the process of cadaveric preser-vation can be undertaken.

The legal and ethical framework governing Body Donation in Europe - A review of current practice and recommendations for good practice

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Within the division, the cadaveric remainsare used for a variety purposes. Prosected spec-imens are used for demonstration within lec-tures and other classes while undissectedspecimens are used by students in dissectionclasses. Several cadaveric remains are also usedfor scientific purposes, both basic and clinicalscientific research. Finally, specimens are usedfor postgraduate, mostly hands-on, teachingand some individual work.

The division is keen to ensure that allbequests are handled appropriately and thatdonors can have absolute confidence in theirprocedures. Thus, no bequests are acceptedwithout the donor having registered theirlegacy and been given appropriate informa-tion upon which to make a decision basedupon informed consent. The division providesa chapel for the use of the relatives of thedeceased and each year arranges a commemo-rative service of thanksgiving. This service isattended by relatives, students and membersof the department. The division also encour-ages, though does not require, students toattend special ethics classes that explore theissues surrounding the donation of bodies.

The number of legacies that are registeredwith the division is considerable; a total ofapproximately 6,400 bequests are currentlyregistered. The number of legacies is reason-ably buoyant, though there have been someyears in which the number received hasdeclined sharply. The majority of donors reg-istered are in an age range from 50-80. Eachyear, the division accepts approximately 150-200 cadavers. Currently, there is a 10 year gapbetween the registering of the legacy anddeath. This difference is of considerable signif-icance for the division, given its high usage ofbodies, because it means that any decline inbequests will be felt 10 years ahead and sothere has to be a degree of forward planning toensure a continuing supply of cadavers.

PERSPECTIVE FROM FRANCE (DOCTEUR O.PLAISANT, MAÎTRE M. CAILLAUD, E. LAFORÊT)

In France, as in many countries, there hasbeen a history of receiving bodies for anatom-ical examination and research that can betraced back to the Middle Ages. However, itremains the case that the legal framework thatregulates the receipt of bodies for anatomicalpurposes is still inadequate and insufficient fora rigorous regulation of the process. Tradition-

ally, anatomy departments have relied upontwo main sources of bodies. One importantsource in France over the centuries, as else-where, came from abandoned bodies whichdepartments of anatomy were allowed to usefor anatomical examination. Up until themiddle of the twentieth century, the othermain source came from hospitals that receivedthe poor for treatment. In cases where theindividuals were unable to pay for treatmentor funeral expenses, and where families didnot collect the bodies of the deceased, hospi-tals regarded exemption from payment as suf-ficient compensation to use the bodies foranatomical research without the need for fur-ther formal consent. In neither case did theseprocedures have any groundings in law. How-ever, during the first half of the twentieth cen-tury, the status of the body gradually evolved,leading in 1943 to a decree forbidding hospi-tals to permit autopsy for scientific purposeswhere it is opposed by the families of thedeceased. In the second half of the twentiethcentury, body donation may only take placeafter explicit consent has been given. Thispractice respects and values the status assignedto the human body. The development of bodydonation centres to accept bodies has resultedin a progressive decrease in the number ofbodies abandoned.

The first legal reference to body donationin France may be found in a law of 1887,which was passed to allow individuals theright to determine their own funeral arrange-ments. This was the first legal reference sug-gesting the possibility that individuals coulddecide the fate of their body after death. In thepreliminary debates that surrounded the pass-ing of this law, reference can be found to“bequeathing one’s body or parts of one’s bodyto public institutions or learned societies”.Though this never became enshrined in thelaw, despite these debates, this law may beheld to provide the first legal foundation gov-erning body donation in France.

It was not until the 1980s that the issuessurrounding donation of bodies was raisedagain in any serious way. This followed anextended period of debate that was begun inthe immediate period following the SecondWorld War and was stimulated by a desire toensure that human dignity could be main-tained in the face of scientific advances. In1991, a report was published by Noelle Lenoir(Ethique et Droit décembre 1991). As the resultof this report and work in the State Council,


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Parliament concluded that it was necessary toformulate the overriding principle of “indivis-ibility of the human body, its respect, its non-commerciality, the need for informed consentof every donor and the protection of geneticpatrimony”. The status of the body was thenwritten into the Civil Code and guaranteed bythe Penal Code and these principles were sub-sequently confirmed by a decision of the Con-stitutional Council in 1994. But this decisionessentially concerned organ donation and didnot take body donation into account; as theintention of the law was to protect the rightsof people making organ donation. These deci-sions enshrined in Law that “safeguarding thehuman person’s dignity against every form ofdegradation and subservience is a principle ofconstitutional value”. Articles within thisCivil Code establish important principles thatset out in more detail the ways in which bodydonation should be regarded. They establishthat everyone has the right to respect forhis/her body, that their body should be regard-ed as inviolable and that their bodies are notthe subject of patrimonial rights. Inviolabilitycan only be overridden in cases of medicalnecessity per se or in the interests of the per-son themselves in situations where they areunable to give consent. Even in this lattercase, the consent of others involved (for exam-ple relatives) should be sought. The CivilCode also sets out a principle of completeanonymity. Neither the donor nor the receivermay know the identity of one another. Finally,the Civil Code renders null and void anyagreements that assign value to the humanbody, its elements or any products derivedfrom it.

This latter provision of the Civil Coderegarding patrimoniality has led to a debatesurrounding the issue of donation for, if theprinciple is laid down that people do not owntheir bodies, this would seem to run counterto the notion of any kind of bequest beingpossible. On one side of the argument, it hasbeen stated that people are able to decide whatis done to their bodies with the importantexclusion that commercial exploitation of abody or its parts is not permissible. Otherswould assert that, though one does not ownone’s body, one does have the right to decidewhat its fate is after death.

Though these provisions of the Civil Codeare clearly of importance and are relevant toany debate surrounding the donation of bodiesfor medical education and research, they have

been taken to refer solely to the governance oforgan donation where the bequest is therapeu-tic in nature and not for scientific, research oreducational purposes. In the preparatorydebates that surrounded the confirmation ofthe Civil Code provisions in 1994, there wereethical discussions raising the possibility oforgan removal for scientific purposes. Loi n°2004-800 du 6 août 2004 officially accepted,for the first time, that organs could beremoved for scientific, and not just therapeu-tic, purposes. However, this law has beenregarded as referring solely to organ donation.Thus, a legal framework regulating specifical-ly body donation for anatomical purposes hasstill to be formulated and enacted.

The only directly applicable legal frame-work that may be taken as applying specifical-ly to body donation for anatomical purposes isthat of Article R2213-13 of the CGCT (CodeGeneral des Collectivités Territoriales). Part ofa larger chapter, it regulates the special policeauthority in funeral matters. This Article per-mits health and research establishments toaccept bodies from donors. In order for anestablishment to accept donation of bodies,the donor in life must have completed a hand-written, dated and signed statement executedby them confirming their wish to donate theirbody. Once the establishment has received,such a declaration it then issues to the poten-tial donor a donor card. This donor card mustbe carried by the donor and has to be producedafter death for a donation to proceed. Estab-lishments cannot refuse donations nor can thewishes of the donor be overridden by theirfamilies after death. Following decease, theRegistrar in the district in which the deathoccurred must receive a copy of the declarationconfirming the wishes of the donor from theestablishment where it has been deposited.Provided there are no medico-legal groundsfor retaining the body, it is released and trans-ported to the receiving establishment. TheArticle states that this must occur within 24-48hr of decease (24hr hours in general and48hr if the establishment, whether private orpublic health, has the equipment to allowgood conservation of the bodies).

Though donations are free, and the estab-lishment is required to meet all cremationexpenses, establishments are permitted torequest a contribution from the donor to helpmeet the costs of the running of the donationservice. However, it should be stressed that itis only for that purpose and not as a payment


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for acceptance of bodies. Though all centresoperate in a broadly similar manner under theprovisions of the CGCT Code, the precisedetails of how the centres manage their activ-ities can vary. One example of how these cen-tres operate is afforded by the Centre for BodyDonation in Paris (established in 1953 by Pro-fessor André Delmas) which, in 1981, becamepart of the Université René Descartes. Prior toits establishment, the only bodies that wereused for teaching and research were those fromwithin the Paris region that were otherwiseunclaimed.

According to the provisions of R.2213-13CGCT, the Centre for Body Donation in Paris,in common with others can only accept bodiesfrom donors if they have given consent duringlife. Additionally, a certificate is also requiredto confirm that the donor was free of knowninfections prior to death. Furthermore, andsince 1995, a precautionary blood test isundertaken. As the result of these medicalprecautions, approximately 10% of bodiescannot be used for anatomical purposes andare immediately cremated. In 2004, 651 bod-ies were received by the Anatomical Laborato-ry of Paris, which is the most important of the27 centres in France. Since 1998, cremationhas been required for all anatomical materialon health grounds and this is explained todonors at the time that their declaration ismade to the Centre for Body Donation in Parisand has to be acceptable to them. The ashes ofthe cremated are buried in Thiais Cemeterywhere a headstone has been erected over agrave that acknowledges the generosity of thedonors.

In conclusion, a legal framework for thespecific regulation of body donation exists butremains incomplete. Work is in progressaimed at the creation of an ethical Charter forbody donation centres grounded on the prin-ciples laid down in the Civil Code concerningthe respect, dignity and confidentiality thatshould surround body donation. Though bodydonations are regulated by the CGCT Codeand, in particular, the wishes of the donor areparamount and must be expressed specificallyin writing prior to death, such additional reg-ulation is still felt to be necessary. This willensure that ethical principles governing bodydonation will be enshrined in the Civil Codeand applied with uniformity at all scientificestablishments.

PERSPECTIVE FROM GERMANY(PROFESSOR F. PAULSEN)

Body donations to anatomy departmentshave recently become a major topic of discus-sion in the “Anatomische Gesellschaft”(Anatomical Society) in Germany. This is dueto the fact that the death benefit (1050 €)paid by the health insurance companies tosubsidize the relatives for the cost of burialetc. was abolished at the end of 2003. Previ-ously, this sum had been available to theanatomy departments to pay for the costs ofthe donation programme. This short reviewwill outline the donation procedures in Ger-many for receiving anatomical bequests andthen describe the steps being taken to fundthese programmes consequent upon thechanges in payment of death benefits.

Normally, the first contact of a potentialdonor is with a department of anatomy in theuniversity nearest to where they live. He/she isthen supplied with an information brochureabout the donation as well as a testamentarydisposition.

Funerals are regulated in Germany by State(Länder) and not Federal law. The donation isalso regulated by State law. The donor mustmake a testamentary disposition, wherebychoices regarding the disposal of their bodyafter death can be stipulated (for examplefuneral at sea). Should a donor wish to donatetheir body for anatomical examination, thesigned form has to be retained in the depart-ment of anatomy. The donor is then issuedwith a donor card which should be kept withtheir personal documents to signify theirintentions following death. In contrast to thesituation in the United Kingdom, upon deaththere is no need for further notification to ahigher authority.

At the moment, the University of Halle (atown with 240,000 inhabitants) has some2000 registered donors. However, the numberof donors registered with a departmentdepends on the size of the medical faculty (i.e.how many students are being taught) as wellas on the size of the town. Thus, the donorsregistered vary considerably between medicalfaculties in Germany from 500 to around6000 donors.

After death, the body is transported (atmost German universities by undertakers) tothe department. Throughout Germany, a vari-ety of embalming methods are used, in mostcases a traditional method based on a formalin


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formula or mainly alcohol or a phenol formu-la. In addition, the Thiel technique for fixa-tion is used at some universities for operationcourses for clinicians. Once adequatelyembalmed, the body is usually stored at 4°Cor in 70% alcohol until needed. The majorityof bodies are used in the dissection course,some in operation courses for clinicians, andless frequently as demonstration objects incourses or for anatomical collections. Once thedissection course has been completed, theremains have to be cremated and the ashesinterred at a local cemetery (or according tothe donor´s wishes). In most cases, the univer-sities have a special burial plot at the localcemetery where urns with the ashes of donorsare buried anonymously.

Normally, at each university one or twoservices a year are held, organized by thedepartments of anatomy with the help of cler-gy of the two main Christian faiths (Lutheranand Roman Catholic). The students who dis-sected the bodies are involved in these servic-es (for example by contributing words ormusic or bringing the urns from the place ofceremony to the burial plot). At some univer-sities, the relatives of the donors are invited tothese services.

An important issue that has had to be tack-led in Germany in the last two years is how tocover the cost of the donor programme. Until2003, the health insurance companies hadcontributed 1050 € in the form of a deathbenefit. This payment was abolished follow-ing a cost explosion in the German HealthSystem from 2000 to 2003. From then on,departments of anatomy and/or universitieswere required to meet the considerable costsinvolved. This has had a major impact ondepartmental and university budgets. In turn,this prompted us to undertake a major surveyto determine the likely effects on donationprogrammes.

The main findings of this survey were that,while some departments were receiving sup-port from their faculty or occasionally fromlocal government (all but one of the medicalfaculties are state universities), nearly onethird of the departments had to pay the costsfrom their own research or teaching budgets.This resulted in significant moves to reducecosts and minimise the impact on the dona-tion programme. Among the measures adopt-ed were: negotiating more favourablecontracts with the crematoria and undertak-ers, rejecting some bequests, adopting anony-

mous burial and establishing a donationaccount. More radical measures under consid-eration included cremation and burial outsideGermany (in one faculty) or omitting a funer-al service altogether.

There have also been attempts to look forcontributions from other sources. A fewdepartments decided to ask students for con-tributions ranging from 30 to 100 € per term.A larger number of departments planned toseek contributions from donors. Some depart-ments encouraged earmarked single donationsor asked for some participation in “travel”costs if the donor lived and/or died more than100 km from the department. Anotherapproach has been to ask donors to take out aspecial insurance policy to cover the completecosts (1,200-1,500 €) or part of the cost oftheir donation, either as prepayment to a spe-cial departmental account or as personal insur-ance. At present, more than one third offaculties have experience in trying thisapproach. It is noteworthy that 1,200 € onlycovers the costs outside the medical faculty:transport of the cadaver to the department,transport of the remains to the crematoriumand burial. The costs for personnel, preserva-tion fluid and other consumables are notincluded. Cost sharing is largely accepted bythe donors because the amount is much lowerin total than what the donor (or their next ofkin) would otherwise expect to pay for burial.Experience shows that these changes havehardly affected the number of bequests madeto departments provided the donors areinformed of the reasons for cost sharing. Someproblems arose in cases where donors who hadalready signed testamentary contracts yearsago were now asked to share costs. Despitethis new situation, there is a constant numberof people from areas not even in the neigh-bourhood of a medical faculty who wish tocommit themselves despite the costs.

Although significant changes in fundingthe donor programme have taken place, theeffects on the education of students have beenminor. Only three departments have indicatedthat they are planning to change the way inwhich they intend to educate their students -e.g. two groups of students would worksimultaneously on a single cadaver, makinggreater use of already prepared or plastinatedspecimens and demonstration material, and areduction in the length of the dissectioncourse.


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In conclusion, there is an active programmeof body donation on a large scale in Germanybut changes in funding the programme havenecessitated a review of how departmentsshould manage the costs and may possiblyrequire a wider review of teaching methods.Cost sharing with body donors is becomingthe norm throughout Germany to compensatethe loss of the death benefit and to maintainthe advantages of dissection for students.

PERSPECTIVE FROM ITALY(PROFESSOR G. MAZZOTTI)

Bologna is one of the oldest anatomydepartments in the world and the first medicalschool to undertake dissection as a means tostudy anatomy and yet the last few decadeshave been difficult ones for both the depart-ment and the school. This difficult periodstems from a decision taken by the ItalianGovernment in 1970 to allow free access tomedical school admissions for applicants intheir first year. The effect of this policy wasthat there was a substantial increase inentrants to medical schools and, at BolognaUniversity, this resulted in some 2000 stu-dents per year being enrolled to study medi-cine. This huge increase in student numbersmeant a radical overhaul of teaching. Themost serious consequence, from the point ofview of anatomy teaching, was the closure ofthe dissecting room facility to allow the build-ing of a larger lecture theatre to accommodatethe additional student numbers. This meantthat it was no longer possible to undertakegross anatomy in the conventional way usingprosected human remains. This decision hascaused considerable damage to the ability ofthe department to teach gross anatomy, notthe least of which has been a progressive lossof staff able to teach gross anatomy on thehuman cadaver. The consequences of this freeadmission policy have now been recognisedand, since this policy was reversed recruitmentto the first year of the medical course atBologna has declined to a more manageablenumber of 300 and the relationship betweenstudents and staff in respect to their teachinghas now been re-established. The departmentis only now contemplating a recovery in itsgross anatomy teaching programme but theprocess of restoring teaching using the humancadaver will require a significant input ofeffort and resource.

At present, in Italy there is no specific lawallowing the dissection of human cadavers foranatomical purposes. The present position isthat unclaimed bodies may be used by depart-ments but, since any unclaimed body may beclaimed by a single religious association, thesupply of cadavers in practice is quite limited.Consequently, although Bologna is now in aposition to restart its gross anatomy teachingprogramme, progress is being hampered bythe fact that as few as one cadaver per yearmight be admitted to the school. The anato-my department is attempting to mitigatethese problems in a variety of ways. It makesuse of plastinated specimens, some organsobtained post-mortem and some specimensfrom obtained from animals and also under-takes surface anatomy teaching and bodypainting techniques. These techniques arecommon for all the medical schools in Italy.

However, the Italian Society of Anatomyand Histology and the Italian College ofAnatomists want to restore a more completegross anatomy teaching programme thatutilises cadaveric teaching alongside theseother techniques. Italian anatomists and sur-geons believe that surgical training in partic-ular needs to involve study of anatomy,including that of the cadaver, as part of thepreparation for specialist surgical training. Atpresent, medically-qualified trainee surgeonswishing to undertake specialist postgraduatetraining are forced to look elsewhere in Europeand the USA for suitable courses employingcadaveric teaching. The consequence of thishas been that a number do not return to Italyonce their training is complete. Changes inItalian law are anticipated that will enable amore extensive programme of teaching to takeplace and remedy this problem. In 2004, theItalian parliament presented a specific lawconcerning the donation of bodies for anatom-ical education and research and will createregional centres where such bodies can be pre-pared and studied. The law, if passed, will per-mit potential donors to express in life a wishto donate their bodies after death for anatom-ical education and research. Such bequests canonly be made by the donor in life and relativeswill not be allowed to consent to donationafter death. Bodies will be allowed to beretained for no more than one year after whichthey must be disposed of.

The presentation of this law highlightssome serious problems for departments ofanatomy as they contemplate restoring cadav-


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eric teaching. There is now a shortage of indi-viduals suitably-trained to undertake suchteaching because of the long period of timeduring which cadaveric teaching has not beenpossible. There is also a severe shortage ofbodies. Consequently, departments are look-ing to the possibility of importing humancadavers into Italy to overcome this shortage.They are also looking to train students indepartments in Europe so that they can returnto Italy to develop teaching programme anew.

The law presented in 2004 has been dis-cussed but not yet approved. Currently, thereis a political will for its approval and the newGovernment re-applied a similar law in Junethe 8th 2007 entitled “ A Proposal for Bodydonation for Study and Research” andapproval should be given in the near future.

The experience from Italy highlights theimportance of continuing to ensure the provi-sion of cadaveric teaching for the re-establish-ment of programmes previously abandoned.This is a difficult and challenging process.

PERSPECTIVE FROM THE NETHERLANDS(PROFESSOR H. VAN MAMEREN)

The notes below describe the present situa-tion concerning the donation of bodies formedical education and research. They shouldbe read in conjunction with the recommenda-tions formulated by the Trans-European Peda-gogic Research that are listed at the end of thisreview. Consequently, only areas where currentpractice in Maastricht or the Netherlands dif-fer from these recommendations are highlight-ed. It is also necessary to state at the outsetthat, in the Netherlands, the term «donor»used preferentially for organ transplantationand is not used in relation to persons who wishto offer their bodies after death to departmentsof anatomy for anatomical examination.

In the Netherlands, all donations are regu-lated by a Law on the Disposal of the Dead(LDD). This law regulates the disposal of bod-ies or body parts after death whatever theirultimate destination. It recognizes threeequivalent final destinations of the body: bur-ial, cremation and medical science (teachingand/or research). In the latter case, it is one ofthe eight universities with a department ofanatomy that formally acts as the authorityaccepting the bequest. In practice, the pri-mary responsibility rests completely with therelevant department of anatomy in the univer-

sity concerned. Once one the three destina-tions listed above is chosen, the other two areexcluded.

Those wishing to bequeath their body formedical education and research must com-plete two copies of a so-called codicil. Theseidentical hand-written documents express thefinal wish of the legatee and are congruentwith recommendation four at the end of thispaper. Both documents are part of a compre-hensive prospectus that describes the proce-dure and its legal and financial implicationsfulfilling the function both of an expression ofintent and information leaflet (as suggested inrecommendation nine). These prospectuses aresent by post to anybody interested in makinga bequest whenever a request is received.Requests for prospectuses can be made by tele-phone or letter but, whenever possible, inter-ested persons are encouraged to write to, orcall, the department of anatomy to ensure thatany remaining questions can be answered. Fre-quently, the general practitioner or a hospitaldoctor at an advice centre or nursing homeacts as intermediary. Sometimes, if the legateeis not able to write by him or herself, a notarycan be called upon to assist and, if that is thecase, any charges incurred are paid by thedepartment of anatomy. One handwritten cod-icil must be returned to the department ofanatomy and then checked for completeness.The other must be retained by the donor andkept with the other personal papers of the cod-icil bearer (as suggested by recommendationten). It is important to state that expressing awish in this way under the LDD, includingthe expression of informed consent, is com-pletely without any financial implications forthe legatee.

In addition to the codicil as called for bythe LDD, the legatee has the option of pro-ducing two further documents that can beattached to the codicil itself. These are:

A. a declaration to be given by next of kin thathe/she/they is/are aware of the final wish of thelegatee (in conformity with recommendationfive):

B. a form specifying any extra costs that thesurviving relatives agree to take responsibilityfor in relation to the final disposal of the body;these could include quality of the coffin to beused, the nature of any religious services, anyspecial wishes of surviving relatives during thefinal cremation or incidentally burial after dis-section.


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The comprehensive prospectus sent to thelegatee is careful to state clearly that donationsmay be rejected by the department of anatomyand pays full attention to the often painfulfeelings that may result from any rejection. Inthis situation, it is the relatives and not thedepartment who are required to make arrange-ments for disposal of the body and pay allassociated costs. There are several possiblecauses for rejection of a potential bequest

A. possible virological, microbiological orother complications:

B. in situations where the body may not beintact (such as following an accident or afterrecent surgery). A special example of thiswould be where organs or tissues have beenremoved for transplantation purposes. In thissituation, the department of anatomy will notaccept the legacy:

C. factors interfering with proper preservationof the body such as extreme or morbid obesityor cachexia:

D. in some universities, when there is no fur-ther capacity to store additional bequests. We,in Maastricht, will not accept the legacy undersuch circumstances, though it is perhaps notby accident that the two religiously-foundeduniversities (Free University Amsterdam,Protestant, and Radboud UniversityNijmegen, Roman Catholic) accept bequestsunconditionally. At Maastricht, we try to dis-courage the relatives of codicil bearers, in caseswhere we are unable to accept a body for rea-sons of a lack of storage, to approach otherdepartments to accept a bequest where firstchoices are unable to accept. Consultationsbetween the eight anatomy chair persons inthe Netherlands take place in cases either of ashortage or surplus of bodies.

At Maastricht, the remains of the cadaversare sent to a regional crematorium for dispos-al after the dissection. However, it should beunderstood that this is not a cremation in anyformal sense. One might even question thelawfulness of this procedure given the fact thatthe only activity permitted in a crematoriumis a real cremation. The procedure has beendiscussed with the appropriate legal authori-ties and has been approved as a means of dis-posal. We consider this provides a good legalframework for our current practice. Otherdepartments in the Netherlands make use ofthe hospital incinerator instead. In view of theposition of disposal of the dead in Netherlands

legislation, thanksgiving ceremonies are notheld (as suggested by recommendations elevenand twelve).

Though recommendations 6, 7, 8, 12, 1314, 15 and 16 do not form part of our currentpractice we could accept them grosso modo,though we would not be inclined to employlectures as the best means to explore the ethi-cal issues surrounding body donation foranatomical examination.

PERSPECTIVE FROM PORTUGAL(PROFESSOR D. PAIS)

The legal regulation of anatomical bequestsin Portugal has been a relatively recent event.Before 1999, there was an almost completeabsence of any legislative framework for theregulation of donations of human bodies foranatomical education and research. The onlylaw dating from before this time was from1913. The law permitted the obtaining bymedical schools of the bodies of those dying inhospitals, asylums and public assistance hous-es provided that they had not been otherwiseclaimed within a 24hr period. The conse-quence of this legal vacuum was that the num-ber of bodies being donated to medical schoolswas very small and the teaching of anatomy bydissection was difficult.

Prior to 1999, there were very few laws reg-ulating human body donation. In 1993, a lawwas passed regulating the donation of organsfor transplantation. However, despite theabsence of specific regulations of anatomicalbequests, no opportunity was taken to extendthis law to include the regulation of anatomi-cal bequests. A particular feature of the 1993Transplantation Law was that it deemedeveryone who died in Portugal to be registeredas a potential organ donor unless they had pre-viously registered a specific wish not to donatetheir organs in this way. People not wishing todonate their organs for transplantation couldapply to the Portuguese Ministry of Health tohave their names placed on a register calledREENDA (Registo Nacional de Não Dadores,or Non-Donors National Record) whichwould record their wish. This list has to beconsulted before organs can be legallyremoved. In drawing up the 1999 law relatingto anatomical bequests, legislators took theopportunity to harmonise the two laws andincorporate some of the best features found inthe 1993 Transplantation Laws into the 1999


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decree laws on anatomical bequests. In partic-ular, in preparing a legal diploma that wouldregulate the use of human bodies or bodyparts, the legislators decided to maximise theresources created for transplantation by shar-ing them with the processes surroundinganatomical bequests. It was also decided thatthe registration of non-donors in REENDA,which in 1993 had been deemed not to applyanatomical bequests, would after 1999 beextended to include anatomical bequests.Consequently, after 1999 compulsory consul-tation of the REENDA record was required ofanatomy departments in Portugal before anydissection could be undertaken. Thus, accept-ance for anatomical examination of the bodiesof people who had registered with REENDAbecame a criminal offence.

In order to monitor this process, followingthe passage of the decree law of 1999 depart-ments of anatomy were also required to main-tain adequate records and, in the case of bodiesof unidentified donors, to keep photographicand genetic records to permit later identifica-tion should it be requested. Departments werealso required to pay all necessary costs associ-ated with bequests (e.g. transportation anddisposal). Finally, exploitation of human bod-ies for commercial exploitation was expressly,and strictly, prohibited.

The Portuguese Government, by passing in1999 the Decree-Law (nr. 274/99 July 22nd),set out clearly the legal framework governingthe use of human bodies and body parts foranatomical education and research. Thus thepreviously uncertain legal framework wasclarified and this, combined with a carefulcampaign by the Portuguese Anatomical Soci-ety to encourage body donation, had a dramat-ic effect on the rate of anatomical bequestswith consequent benefits for anatomical edu-cation in Portugal.

The Decree-Law of 1999 consists of 22 sep-arate articles and it is outside the scope of thisarticle to summarise all the aspects of this law.However, some of its key provisions will bedescribed. The law covers the dissection of allbodies and body parts both for Portuguese cit-izens and people from other countries who areresident in Portugal and who die in Portugal.One very important aspect of this law is thatit establishes the principle that anatomicalbequests can be made by donors during theirlife. Following the confirmation of death by amedical practitioner, the anatomical examina-tion of bodies may be undertaken by medical

schools, forensic institutes and departments ofpathology. The Decree-Law of 1999 allowsdissection of a body or body parts only if thedonor, in life, has expressed a wish to donatehis or her body for this purpose. However, ifsuch a wish has not been expressed in life,donation of the body is still permissible pro-vided the donor has not placed their name onREENDA or if the body remains unclaimedafter 24 hr. Should a body that has not beenclaimed and has been taken for anatomicalexamination be subsequently claimed, thenthe body can still be retained by a Departmentuntil the scientific examination is complete.

The Decree-Law of 1999 makes severalother important provisions. It requires thatadequate records must be maintained, includ-ing a record of what examinations were madeon the cadaver. It requires that these recordsbe held securely and that they must remainconfidential (except for the purposes of legalor police enquiry). Departments are expectedto pay all the associated costs of a bequest andare deemed to be responsible for disposal byburial or cremation. During the time that thebody is retained within a department adequatepreservation measures must be employed toensure that the human remains are treatedwith respect. As with the transplantation lawof 1993, any commercial exploitation ofbequests is strictly forbidden. Finally, the lawplaces upon medical schools a duty to ensurethat the students who use the cadavers receiveinstruction so that they develop respect for thecadavers upon which they receive suchinstruction.

Shortly after the enactment of the DecreeLaw of 1999, the Portuguese Anatomical Soci-ety (Sociedade Anatómica Portuguesa, SAP)undertook the production and broad distribu-tion of a leaflet called Doar É Humano(Donating is Human). This leaflet encouragedthe donation of bodies for anatomical exami-nation and was widely-distributed to hospitalsand health centres and combined with a pub-licity campaign on television and radio. Theeffect upon the rate of donation has been dra-matic. In the department of anatomy in theNew University of Lisbon, donations haverisen sharply in numbers from 73 in the entireperiod from 1984 to 1999 to 354 in the fiveyears following 1999 (with 191 of those dona-tions being made in 2004 alone).

The vigorous campaign of PortugueseAnatomists for a proper legal framework togovern bequests for anatomical education and


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research has been of major benefit to anatom-ical education in Portugal. It is now possibleto provide medical students with a more fully-grounded education based upon the teachingof cadaveric anatomy and providing themwith a fuller preparation, in terms of theirunderstanding of anatomy, for their subse-quent medical careers.

PERSPECTIVE FROM ROMANIA(PROFESSOR A.R.M. CHIRCULESCU)

In Romania, at present the use of bodies foranatomical education and research is not gov-erned by any special laws. In my opinion, asingle unifying legislative framework isrequired to cover all donations and manipula-tions of human tissues (including material formedical education, pathology and research).Section VI of the new “Law regarding the ref-ormation of the health care system” of the 29th

of March 2006, and which comprises six chap-ters (articles 141 to 164, each with 2-12 para-graphs), substitutes the Law n.2/1998 on theremoval and transplantation of human tissuesand organs and the Law no. 104/3rd of April2003 on manipulation of human cadavers, andon the donation and removing of organs andtissues from cadavers, but itself refers only toorgan and tissue transplantation. That sectionof the law was considered by the two Cham-bers of the Romanian Parliament, when theyvalidated the law, to be in conformity withDirective 23/2004/EC of the European Parlia-ment and the Recommendation of the Euro-pean Council from 31st of March 2004, whichlays down quality and safety standards for thedonation, testing, processing, preservation,storage and distribution of human tissues andcells (as highlighted in the last paragraph ofchapter VI of that law). Within the laws so farpassed, Romanian Legislators have indicatedtheir willingness to move towards a harmo-nization of Romanian legislation with that ofEurope in all other related fields. However,thus far, specific regulations on body donationand use for medical education and scientificresearch, regarding pathology, anatomy,embryology, fertility materials and cloning arestill lacking. There is also no Code of Practiceto regulate the activities of anatomy andanatomists, nor a Code concerning the respect,dignity and confidentiality that should sur-round bodies used for medical education.

In the absence of specific laws regulatingthe donation of bodies for anatomical exami-nation, anatomy departments are permitted toclaim the otherwise unclaimed bodies ofpatients dying in hospitals, workhouses andother health care institutions. The claiming ofsuch bodies by anatomy departments ispresently under police control. The conse-quence of this arrangement is, therefore, thatno consent is needed to be given in life forone`s body to be used for anatomical examina-tion following decease. The current arrange-ments are regarded as a form of donation fromthe health care institution concerned to thedepartment of anatomy, on the basis of directbilateral agreements (see below).

There is no legal or official involvement ofthe Romanian Anatomical Society, of theRomanian Academy of Medical Sciences, or ofa special Officer or Commission of the Gov-ernment or other State authority in establish-ing rules for either research on human bodyparts or tissue supply, manipulation, storage,use and disposal of cadavers for anatomicaleducation or in supervising such activities.However, the Board of the Anatomical Societydoes wish to become more actively involved.Thus far, its attempts to take an initiative inthis direction have not been successful,though a workshop on body donation wasorganized during the VIth National Congressof Anatomy, in Iassy (June, 2002).

Despite the lack of a true national legalframework regulating the donation of bodiesfor anatomical examination, anatomy depart-ments within the medical schools in Romaniado observe several general principles in theacquisition and use of bodies for anatomicaleducation and research.

All Romanian medical schools have agreedto provide medical students with an anatomi-cal education based upon the teaching ofcadaveric anatomy. Therefore, each of them,whether public or state medical schools, hasdeveloped its own way of acquiring cadaversfor the education of medical students andresearch. This applies equally to what mightbe termed the older, and more traditional,schools in Bucharest, Cluj, Iassy, Timisoara,Targu Mures, Craiova add the newer schoolsfounded during the last 16 years, Constantza,Brasov, Sibiu, Oradea, Galatzi and the twoprivate schools in Bucharest and Arad, listedin order of their foundation. At present, it istrue to say that practically no rule is appliedwith uniformity at all scientific establish-


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ments and the details of accepting and regis-tering the body after death vary between dif-ferent departments of anatomy. However, thesame general approach is adopted throughoutonce a decision is taken whether or not toaccept the body for anatomical examination.

Within the confines of this brief review, itis not possible to detail the diverse arrange-ments that exist in so many different schools.Instead, this review will confine itself to adescription of the procedures currently in usein Bucharest. The faculty in Bucharest is theoldest (1857) and largest (about 400-1,000students a year) in Romania. The buildinghousing the department of anatomy with itsfive dissection rooms and the museum ofanatomy has been in use since 1901.

In Bucharest, the head of the department(or a deputy nominated by him) has good con-tacts established with the managers of the hos-pitals, workhouses and other public healthcare institutions from Bucharest and the areasurrounding it within a radius of about 100km. The head of the department asks them tosupply the dead bodies of individuals other-wise unclaimed. The arrangement is that thehospital administration will contact the chieftechnician of the departmental mortuary unit(“service of cadavers”) if they have anunclaimed cadaver, usually 24 hrs after death.The necessary legal documents are completedin the hospital and sent together with thebody. Bodies are transported to the depart-ment by the university administration in avehicle specially-designated for the purposeand by agreement with the police.

Under normal circumstances, no offer of acadaver is refused and there is no limit on thenumber of acceptances that can be made.Selection of suitable cadavers is carried outwithin the departmental mortuary based ondirect examination of the body. Those consid-ered not suitable for dissection are eitherimmediately cremated (if very badly dam-aged) or used for the preparation of individualbones.

At present, no precautionary blood tests areundertaken. However, it is considered thatprecautions do need to be extended towardsthe possible hazards posed to staff of newly-emerging diseases that may survive theembalming process, such as Jacob-Creutzfeldtdisease and its variants.

Full records of acceptances are kept locally,in the department, by the chief technician ofthe departmental mortuary unit under the

supervision of a member of the teaching staff.There is no central authority to control thisactivity. These records are held securely andremain confidential, except when required forthe purposes of legal or police enquiry.Departmental records are supervised by thepolice and subject to checks randomly or whenneeded.

The number of cadavers collected variesfrom 17 to 25 per year, ranging in age from 50to 80, from which about 2-3 are not used dueto their condition. Cadavers are fixed by a con-ventional traditional method based on a saltedformalin and phenol formula. Once adequate-ly embalmed, the bodies are usually storeduntil needed in tanks filled with the samefluid. No alcohol and/or glycerol mixture isused. The so-called natural method ofembalming (Thiel technique or other softermethods) is not in use in Bucharest.

The cadavers accepted into the anatomydepartment are used for a variety of purposes.Most are used for teaching in the dissectioncourse. Prosected specimens are used fordemonstrations, while undissected bodies areused by students in the dissection classes,which are part of their anatomical studies.Each group of about 100 students uses 2-3cadavers a semester. A number of bodies areused for a variety of postgraduate surgicaltraining courses. Less frequently, parts ofcadavers are used as demonstration specimensin courses or in anatomical collections. Theuse of material can also extend to providingspecimens for basic and clinical research andfor surgical training. There is normally noexchange of cadavers and body parts betweenanatomy units.

There in no specific regulation for the useof body parts for research. Instead, such deci-sions are left to the discretion of each anatomydepartment. In Bucharest, graduate students,researchers and clinicians are allowed, andencouraged, to develop their research. Thiscan be contrasted to the strictly regulated pro-cedures in pathology departments, where anyresearch project using organs or body partsfirst needs approval from the Ethical Commis-sion of the Medical Faculty.

Anatomical specimens may be retained aslong as needed. As there is no legal time limit,the storage and use of cadavers or parts ofcadavers will largely depend on their individ-ual condition. In the case of well-preservedmaterial, it may be retained for two-threeyears or more.


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Upon completion of the anatomical exami-nation, the cadaveric remains are disposed ofby cremation. Cremation has been required forall anatomical material on health grounds.The ashes of the cremated are not buried. Allthe associated costs of disposal are covered bythe university.

The medical school is not required toensure that the students who use the cadaversreceive special instruction in developingrespect for the cadavers they use. The depart-ment neither encourages nor requires studentsto attend special ethics classes to explore theissues surrounding the donation of bodies.

There are no legal restrictions, require-ments for special licensing, or measures tocontrol the public display of anatomical mate-rial; images of the material in the dissectingroom can be also taken, (usually) and only theconsent of the head of the department isrequired.

Romania is a diverse country from thepoint of view of religious observance and thisdoes raise sensitive issues surrounding theopportunities that there might be for a form ofreligious Service of Thanksgiving for thedonors. The staff and students who dissectedthe bodies are not involved in any sort of spe-cial event, either religious or secular. Therewas an attempt to organize such activitiessome 15 years ago, under the auspices of theSociety of Medical Students from Bucharest,but it has not become a regular event in theyears that have followed.

In summary, there is no national frameworkof legal regulation for the acceptance of bodieswithin Romania. Instead, individual depart-ments follow locally-determined procedures,though many aspects of these local proceduresare broadly similar between different medicalschools.

PERSPECTIVE FROM SERBIA(PROFESSOR G. TEOFILOVSKI-PARAPID)

The Institute of Anatomy of the School ofMedicine at the University of Belgrade(SMUB) is the oldest anatomy department inSerbia and Montenegro, which is understand-able when it is remembered that the School ofMedicine at the University of Belgrade hasbeen the parent school for all other medicalschools in Serbia and Montenegro (i.e. Schoolof Medicine in Novi Sad, Nis, Pristina,Kragujevac and Podgorica).

The first written signs of medicine in Ser-bia can be traced back to the XII century – thefirst Serbian hospital was organized in 1199 inthe monastery of Hilandar (Mount Athos, nowin Greece) and, in 1208, in the monastery ofStudenica (now in Serbia). The first initiativeto establish the University Medical School wasrecorded only in 1876, and the first Universi-ty law was passed in 1905, by which the GreatSchool of Belgrade was transformed into theUniversity of Belgrade, and the School ofMedicine was officially founded as one of its 5constituent Schools. Due to the poor econom-ic and security situation (The Balkan war in1912, and the First World War) the School ofMedicine at the University of Belgradeenrolled its first class students only in 1920.The first lecture in the newly opened schoolwas an anatomy lecture given by Prof. NikoMiljanic on December 9, 1920. The Instituteof Anatomy was organized as a copy of “Ecolepratique de la Faculté de Médicine” and“Ecole de Clamart” in Paris, and first bodyremains used in the teaching of anatomy werethe 6 skeletons brought from Paris by Prof.Miljanic. In the same year, the King signed aspecial legal act permitting and regulating theprocedures for collecting the remains of aban-doned persons deceased in hospitals all overSerbia. The campaign launched by the Schoolof Medicine was so successful that, by thespring of 1921, the institute had a total of 99cadavers, enabling the beginning of studentanatomical dissections in May of the sameyear.

Between 1921 and the end of the SecondWorld War, body collection for medical stud-ies was strictly regulated by the aforemen-tioned legal act. Consequently, the remainsfrom those who died in hospitals with no fam-ily or relatives to claim the body were sent tothe Institute of Anatomy at SMUB. AfterWorld War II, the communist regime sus-pended all legal acts and among them the onerelated to body bequests. After that time, inanswer to numerous school requests, somepartial legal acts would be enacted allowingthe donation of unclaimed bodies, but bodybequests were not forthcoming because noneof these partial acts compelled hospitals,municipal offices or other institutions toinform the departments of anatomy of theexistence of an identified deceased individualwhose body might be suitable for teachingpurposes in a medical school. Hence, in 2003there was only one article (article 84a of the


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Health Protection Law) referring specificallyto the collection, by departments of anatomy,of the unclaimed bodies of individuals with nofamily members for the study of anatomy atmedical and dental schools. In 2004, inresponse to this lack of a suitable legal frame-work, the Institute of Anatomy at SMUBlaunched a campaign for body donation. Thishad the effect of increasing the number ofdonations, but not substantially that of cadav-ers. Fortunately, in 2006, the new Health Pro-tection Law was passed in the parliament ofSerbia (the relevant articles of the draft werepresented at the meeting of the TEPARG heldin Paris in March 2005). It contains more arti-cles related to the issues surrounding bodydonation but also makes reference to otherissues, including organ donation for trans-plantation and fertility treatments. It is thefollowing articles, i.e. articles 225 through233, reproduced below that regulate very pre-cisely the activities associated with the processof collecting human body remains for theteaching of anatomy:

X Harvesting, Organ and Body Parts’Transplantation

Article 224. Organs, tissues and cells – asparts of the human body – can be harvestedand transplanted only if medically indicated,i.e. if it is the most adequate procedure fortreatment and if the laws regulating it arefully complied with.

Procedures and conditions for cellular, tis-sue and organ harvesting and transplant forfertility treatments via assisted reproductionand conception will be regulated by a separatelaw.

XI The Recovery of Dead Bodies for the Purposesof Practical Teaching

Article 225. Schools of medicine and othermedical vocational schools can recover thebodies of dead and identified persons for thepurposes of practical teaching:

1. if the deceased has specifically, in writ-ten form, donated his body for practical teach-ing purposes

2. if the body of the deceased is notclaimed by any family members and has not,prior to his or her death, specifically refusedbody donation

3. if the family gives consent, providingthe deceased has not, prior to his or her death,specifically refused body donation

(Item 1 constitutes a Body Donation Con-sent and it has to include the name of theexecutor of the person’s will and must havebeen legally verified in Court.).

Article 226. The following persons are consid-ered as family: spouse (married or live-in), chil-dren born within or out of wedlock, adopted oradoptees, legal guardians, parents, relatives insecond lineage regardless of the consanguinity,as well as lateral relatives, including the thirdlineage of the consanguinity.

Article 227. Within the 12h of a potentialbody donor’s death, the following are com-pelled to report it to the local MunicipalOffice: medical institutions, correctional facil-ities, welfare institutions, local Courts, localPolice Departments or citizens in possession ofknowledge of a recent death of the aforemen-tioned.

The decision concerning the acceptance of adonated body will be made by the EthicsBoard for Anatomy of the medical school con-cerned.

The school can accept a body for practicalteaching purposes only if the death certificateis signed by the local Coroner and in situa-tions where no mandatory autopsy is required.

Article 228. The school is not allowed to usethe bodies of deceased individuals where nofamily members have come forward to claimthe body until 6 months have elapsed after thebody has been accepted.

The school will not accept the body of aperson who has died due to infectious diseaseor those who present with postmortemchanges that will prevent embalming of thebody to occur.

The school takes responsibility to treat thebody with proper respect, to use it only forpractical teaching purposes and to bury it oncompletion of teaching.

The school will agree to carry out thedonor’s last wishes regarding burial, crema-tion, and the type of religious ceremony andany other clearly stated wishes.

The school may use the bones of the donat-ed body to prepare an osteologic set (skeleton)which will be used for practical teaching inanatomy, providing the donor has expressedtheir consent in life.

Article 229. The school can accept bodiesunder the conditions laid out in Art. 225 (2)previously mentioned only after the localMunicipal Office has given consent.


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The Municipal Office is bound to informthe school of the existence of an identifieddeceased individual whose body can be usedfor teaching purposes in schools of MedicalVocation regulated by this law.

Article 230. In cases where a family memberunknown at time of death submits a request tothe school claiming a body previously uniden-tified within the specified six month period,the school must return the body to the family.

Article 231. The school is bound to keep as apermanent record all the data and documentsregarding the bodies of deceased individualthat have been accepted for practical teachingpurposes.

These data include: the last and first nameof the deceased, their date of birth, place anddate of demise, the cause of death and number(matching the number on the marker suppliedwith the body of the deceased).

The aforementioned documents include:the Coroner’s report, death certificate, ID,health certificate and a written statement con-firming the donation.

Article 232. Bodies donated for the purposesof practical teaching in anatomy may be usedby the undergraduate students and postgradu-ate students and residents of the school, butonly under the supervision of the teachingstaff.

Article 233. Bodies no longer required foranatomy practical teaching will be buried.

The burial is announced in the appropriateobituary section, while present at the ceremo-ny members of the School teaching staff andstudents of the school. An appropriate reli-gious ceremony will be held if that forms partof the last wishes of the donor.

In conclusion, it can be said that thedetailed legal framework that is provided bythe Health Protection Law on one the hand,alongside the intensive campaign launched byeach medical school in Serbia on the other,will certainly help in the acquisition of bodiesdonated for anatomical examination in thenumbers necessary for an ongoing medicaleducation of high quality.

PERSPECTIVE FROM SPAIN (PROFESSORS J.R.SAÑUDO, J.L. BUENO-LÓPEZ, F. DOÑATE-OLIVER)

Current Spanish legal regulation on use ofcadavers for scientific teaching and research

encompasses a body of subsidiary laws datingback to 1932, when an “Orden del Ministeriode la Gobernación”, of October 31, was pub-lished. This Order, made by the Spanish Min-istry of Interior Government, regulates thestorage of human bodies for use in medicalschools. This 1932 Order has since beendeveloped by means of a number of orders anddecrees made subsequently. Of these orders,only two important procedures will be focusedupon in the brief review that follows. Theseare:

“Decreto #2263/74 del Ministerio de la Gob-ernación” of July 20, 1974. This Decree regu-lates the Mortuary Sanitary Policy andparticularly the rules applying to the transferof cadavers to cemeteries and, in addition, theuse of human bodies and remnants in medicalschools.

“Decreto #106/1996” of June 11, 1996. ThisDecree of the Department of Health, SocialWelfare and Work is an updating of the gen-eral Mortuary Sanitary Policy regulated by theDecree just quoted above.

However, it is important to understandthat Spain is now a quasi-federal (and in somelegal aspects a truly federal) Kingdom. Hence,the jurisdiction regarding these Sanitary andMortuary Policies, among many others, hasbeen transferred from the Spanish Govern-ment to the regional Governments of the so-called Autonomous Communities of theKingdom of Spain. Common Sanitary andMortuary Policies have consequently devel-oped, since 1980, into regional branches oflegal regulation in the Autonomous Commu-nities. Where these regional forms of legalregulation exist, the Common Law will thenstill apply but in a subsidiary mode and onlyin circumstances where the particular regula-tion of any Autonomous Community is shownto be void or subject to ambiguous interpreta-tion. As a result, the regulation across Spain isbroadly similar, though understandably varia-tions from one Autonomous Community tothe next will occur. As a way of illustratingthese regional regulations, a translation ofChapter V of the Rules for Mortuary Policy ofthe Andalusian Community is given below.

Chapter V. On the use of human bodies and otherhuman remains for research and teaching

Article 25. Human bodies and remains encompassedwithin Group 2 of Article 4 of the present Rules


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may be used for scientific research and teaching pro-vided that the following conditions have been com-plied with:

a) Donors must have expressly stated their inten-tion in life to donate their body for anatomicalteaching and research after death.

b) Identified persons who have not been reclaimedby their relatives within the first 24 hours afterdeath. In addition, the cause of the death must beadequately certified, no legal case should be inprocess, and no opposition to such use of the cadavershould be expressly made by the deceased prior todeath or by relatives of the deceased.

Article 26. Transfer of human bodies and remnants. Human bodies to be used for scientific teaching or

research must be transferred in individual coffins tostorerooms that medical schools must have availablefor this purpose. Similarly, the transfer of embalmedhuman bodies between schools of medicine must bealso be made in individual coffins.

Article 27. Storage of human bodies and remnants.The storerooms for human bodies in the schools of

medicine will be organised and regulated in accor-dance with the particular requirements for teachingand research of each school. The storerooms will thenbe under the sanitary regulation of the Service ofLabour Health of the university of which the med-ical school is a part.

Article 28. Transfer to final placement of humanbodies and remnants.

After completion of anatomical examinationteaching and research, the embalmed human bodies,or their remains, can be transferred into a commoncoffin for final disposal that should be in mannerthat is in agreement to the said Article 5 of the pres-ent rules.

Article 29. Human bones.Human bones obtained from cemeteries will have

no sanitary status in law if they are to be kept inteaching museums or other teaching premises.

In conclusion, the end result of the Spanishregulation for the use of cadavers for scientificteaching and research is, in our opinion, suffi-ciently detailed to ensure standardization ofpractice across Spain yet at the same timebroad enough in scope to allow for unambigu-ous interpretation in all eventualities.

Having examined the legal framework reg-ulating body donation in Spain, it is now pos-sible to describe some of the detailedprocedures that occur between a donor regis-tering their intention to bequeath their bodyfor anatomical teaching and research and even-tual disposal once the examination is complete.

The intention to donate has to be made by anindividual in person during their life. Thedonor is required to sign a bequest form(which in some cases must be witnessed by twopeople whose signatures accompany that of thedonor on the bequest form). One copy of thebequest form is retained by the relevantdepartment of anatomy and the other by thedonor, together with a Donor Identity Card.There is no notification made to a legal author-ity at the time that the donor registers theirintention to donate their body after death.

Only the department, but not the teachersnor the students who eventually dissect thebody, may know the identity of a donor. Upondeath, the mortuary is informed, a judge isasked for permission for a transfer to be madeto the department of anatomy, and then themortuary transfers the body to the department(at no cost to the relatives) within the 4/48hours following death. Families do not have alegal right to stop the process. Bodies can betransferred to a department different to theone to which the donation was originallymade. This is no longer as expensive a proce-dure as it once was. In the past, each countyand municipality across which the body was topass had to grant legal permission for thetransfer to be made and a tax was levied oneach transfer. This is no longer the case.

Once the cadaver has been received by thedepartment concerned, a series of legal issuesarise during the time that the body isretained. The legal position in Spain regard-ing the ownership of the cadaver is somewhatdifferent from that of many other Europeancountries. In Spain, nobody owns a cadaver orcadaveric remains after death. However, thereis a responsibility for its safekeeping placedupon the department that receives it, the per-son who is ultimately charged with the dutyof ensuring that responsibility is carried outbeing the head of department, dean of the fac-ulty or vice-chancellor of the university.Throughout the time that the body is retainedby the department, the appropriate health andsafety regulations must be adhered to ensurethe safety of all staff and students who maycome into contact with the cadaver or cadav-eric remains.

The disposal of the remains after dissection,or following any other use, (e.g., surgicalcourses) is by burial or cremation. In recenttimes, some universities (e.g., those of theBasque Country and Murcia) have built mon-uments to the memory of the donors.


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Thus, in Spain body donation is a very dif-ferent procedure when compared with organdonation, which is regulated by another bodyof law and acts coming from the “Ley Generalde Sanidad 14/1987”. According to thoselaws, every Spanish citizen is a potential organdonor, (unless they state otherwise duringlife), which is in sharp contrast with the needfor explicit consent that must be given in rela-tion to anatomical bequests.

In summary, donations are to be made withfully informed consent. Donors are required tofill in and sign a document confirming theirwish to donate their body for anatomical edu-cation and research. No payments are made todonors or to their relatives, and departmentsdo not guarantee that donations made in lifewill be accepted after death. Some conditionsthat may result in rejection of the body are: aprevious autopsy, a transplant donor (excepteye donors), the amputation of limbs, morbidobesity, cachexia, a history of tuberculosis,hepatitis C, gangrene, Alzheimer’s disease andHIV.

A more comprehensive summary of theseissues and others relating to the running ofdissecting rooms has been published by theSpanish Anatomical Society in a documentcalled “Acta de Barcelona” which can beviewed and downloaded from the SpanishAnatomical Society website (Spanish Anatom-ical Society, 1996).

PERSPECTIVE FROM SWITZERLAND(PD DR B.M. RIEDERER, PROF. P. SPRUMONT)

Switzerland is a federal country with theindividual Cantons having autonomy overmany administrative matters, includinghealth and education. Thus, though there areFederal laws that regulate a range of issuesthat touch on anatomical bequests there is nonational regulation of anatomical bequeststhemselves, for this is a matter of local Can-tonal law. However, Federal laws deal withsuch matters as transplantation medicine, dataprotection (including privacy and confiden-tiality rights), genetic analysis and productionof therapeutic products. Clearly, all the regu-lations governing these important issues willoverlap in places with any laws on anatomicalbequests. Nevertheless, the six Swiss anatomyunits remain regulated solely by the laws ofthe Canton in which they are situated.Though there is no national framework, of

regulation the forthcoming law on Researchon the Human Being may have provisions thatmight be held to apply to anatomical donationand the Swiss Academy of Medical Scienceshas issued several directives (on experimentalresearch on the human being; on the defini-tion and diagnosis of death, and on ethicalproblems relative to intensive care) that bearindirectly on this matter.

Despite the lack of a true national legalframework, there are some principles thatcould be said to apply to all donations of bod-ies for anatomical education and research inthe six Swiss anatomy units. These are: dona-tions should be made with fully informed con-sent; all donors are required to complete andsign a document confirming their wish todonate their body for anatomical educationand research; no payments are made to donorsor to their relatives; departments do not guar-antee that donations made in life will beaccepted after death. Under these local laws, atotal of approximately 195 cadavers wereaccepted for embalming by Swiss anatomyunits in 2006; 135 of these were fixed by con-ventional procedures (Jores or similar tech-nique) and 60 by new, so-called, naturalmethods (Thiel technique).

In order to ensure that potential donors arefully informed about the process of donation,anatomy units in Switzerland produce infor-mation leaflets that are sent to donors at theirrequest. These vary in their detail but not inthe basic information they provide. At theirmost straightforward, they simply provideinformation about the conditions under whichbequests can be accepted. At the time of dona-tion, potential donors are required to completea donation form to register their wish todonate their body for medical education andresearch. This form has to bear their signatureand must be witnessed. Donors also sign toagree their assent to the conditions underwhich donations are accepted, including thefact that there is no guarantee that an anatomyunit will accept a donation upon decease. Some800 bequest forms are actually filed in theanatomy unit of Fribourg. Less than 2 % of thecadavers brought to the unit are rejected.

The bodies that are accepted into the anato-my units are used for a variety of purposes.Many are used for teaching. In all but one ofthe anatomy units, students are required toundertake dissection as part of their anatomi-cal studies. This is compulsory for students intheir first three years of training in most med-


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ical schools and optional for students in theirlast three years of training in half the medicalschools. In addition, a number of bodies areused for a variety of postgraduate surgicaltraining courses. The majority of these cadav-ers are embalmed by the softer, and more nat-ural techniques, that are better suited for thispurpose.

Some bodies are also used for investigationpurposes (mostly in surgical research) andthere are also requests for body parts andcadavers for a variety of other therapeutic pro-cedures. Medical institutions, both public(e.g. hospitals) and private (e.g. training cen-tres in orthopaedics), increasingly requestbody parts, as well as whole cadavers, for clin-ical research purposes. There is also an increas-ing trend towards carrying out various testsfor therapeutic devices on body parts import-ed into Switzerland from other countries.

Upon completion of the anatomical exami-nation, the cadaveric remains are disposed ofby cremation. In most cases, they are cremat-ed and interred together, but they may also beinterred separately. In either case, they areburied in a reserved and marked area of one ofthe local cemeteries. However, should thefamily request so, the remains of an individualbody can be returned to the family for com-mittal.

In recent years, it has been possible to iden-tify a number of trends amongst the Swissanatomy units relating to practices surround-ing the management of the process of anatom-ical bequests and the subsequent handling ofhuman remains. These changes may necessitatesome rethinking about the way in whichbequests are accepted and subsequently howhuman remains are cared for. Three main areasare worthy of mention here. (1) There has beena process leading towards harmonisation ofinformation and the development of a nationalsystem of handling bequests. (2) There is anincreasing tendency toward the exchange ofcadavers and body parts between anatomyunits according their special needs. (3) Unitsare looking ever more carefully at an evaluationof the costs of various anatomical proceduresand at the impact this may have on future pat-terns of anatomical bequests. As the result ofthese trends, there need to be some develop-ments in the procedures surrounding the dona-tion of bodies for anatomical purposes.

The use of body parts for research needs amuch stricter form of regulation. At the pre-sent time it is left to the discretion of each

anatomy department to obtain the necessaryinformation from research groups concerningthe purposes for which body parts are to beused. It also depends on the institutionaldirectives, as donors have formally agreed tothe use of body parts for teaching and researchpurposes by signing the donation forms. Thisis in contrast to the strictly-regulated proce-dures in pathology departments where anyresearch project using organs or body partsneeds first to be approved by the ethical com-mission of the medical faculty.

With the development of new techniquesin body preservation (e.g. plastination), bodyparts and well prepared specimens last muchlonger and are ideal tools for teaching humananatomy. Therefore, it is not surprising thatinstitutions that use these techniques receivemany requests asking whether they will sellhuman body parts. In Switzerland, the sale ofbody parts is forbidden by law and donorforms also stipulate that donated parts willnot be sold. Furthermore, any commercial useof plastinated human body parts is unethical.However, plastinated body parts may be lentfor a defined time to neighbouring medicalinstitutions for clinical or anatomical teach-ing, as already outlined above.

In addition to the necessary further devel-opments of the law in Switzerland, there needsto be regulation of transport of human partsacross national borders in order to ensure thatpublic confidence in the process of bequestingtheir bodies remains high. There also needs tobe more research into the possible hazardsposed to staff by newly-emerging diseases thatmay survive the embalming process (e.g.Jacob-Creutzfeldt disease and its variants).Finally, there needs to be more public infor-mation to ensure adequate understanding ofthe importance of anatomy to medical practicein order to encourage future donors to comeforward and bequest their bodies for anatomi-cal education.

PERSPECTIVE FROM THE UNITED KINGDOM(PROFESSOR B.J. MOXHAM AND PROFESSOR S.MCHANWELL)

The bequest of bodies for anatomical edu-cation and research has been governed by lawscontained in a series of Acts of Parliament, theAnatomy Acts of 1832, 1871 and, morerecently, 1984. The early history and the rea-sons for the introduction of the Anatomy Acts


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of 1832 and 1871 has been described in detailby Ruth Richardson (2001) and so do not berepeated here in detail. The 1832 Act wasostensibly introduced in response to the pub-lic outcry following the prosecution and con-viction of Burke and Hare and the subsequentexecution of Burke in Edinburgh (Hare wasreprieved in return for his co-operation insolving the case). However, Richardson (2001)argues persuasively that the principal purposeof the Act, through the permitting of theunclaimed bodies of paupers dying in work-houses to be claimed by anatomy depart-ments, was to make those same workhousesplaces to be feared. The willingness of somedepartments to claim pauper’s bodies rathertoo quickly, before relatives had been givenadequate time to claim them, resulted in aseries of public scandals. Nevertheless, it wasanother fifty years before the Act of 1832 wasreplaced by the Anatomy Act of 1871, theprincipal purpose of which makes provisionfor consent to be given in life for one’s body tobe used for anatomical examination followingdecease. Thus, the intention of the Act of1871, in allowing donation by consent, wasvery much in keeping with the public spirit ofthe times. This Act served its purpose well forover one hundred years, with just some minoramendments being added to make the 1984Anatomy Act. In 2004, however, these Actswere replaced by the Human Tissues Act. Inrespect of the regulation of anatomicalbequests, the Human Tissues Act built uponthe practice of the earlier Acts. Consequently,in order to understand how the new Act oper-ates, it is necessary to understand what pre-ceded it. This knowledge is also a prerequisitefor understanding the ways in which the newAct differs from its predecessors.

The Anatomy Acts of 1871 and 1984 reg-ulated two major aspects of practice in relationto the bequest of cadavers for anatomicalexamination. The Acts licensed premises inwhich the bodies are to be stored, maintainedand examined and they also licensed individu-als who were then responsible for ensuringthat the provisions of the Anatomy Acts areconducted within the licensed premises. Theoperation of the Act was overseen by HerMajesty’s Inspector of Anatomy.

Licensed premises for the storage of humanbequests had to be secure and suitable formaintenance of bodies in a good conditionsuitable for examination. Access to the prem-ises had to be controlled and restricted to

teachers of anatomy and bona fide students.The operation of the licensed premises wasunder the direction of a “Licensed Teacher (orTeachers of Anatomy)”. Licensed Teachers hadto be of ‘good standing’. Their appointmentswere approved by a magistrate. LicensedTeachers had many responsibilities under theAnatomy Acts. They were responsible forensuring that proper consent for bequest wasobtained prior to death. Once the body wasreceived after death, Licensed Teachers wererequired to inform the Inspector of Anatomyof the receipt of the body. Licensed Teachershad to ensure that proper records were keptlocally of all donations received and also thatrecords were held centrally by the UK Gov-ernment’s Department of Health. LicensedTeachers had also to make the licensed prem-ises available for annual inspection by theInspector of Anatomy. Licensed Teachers wereresponsible for the proper conduct of premisesin which the bodies were held. This includedrestricting access only to teachers of anatomyand bona fide students, not allowing humanmaterial to leave licensed premises withoutofficial approval, ensuring human materialwas used only for anatomical examination andnot surgical practice, and not allowing pho-tography that might permit recognition of thedonor.

The operation of the Anatomy Act wasmonitored within the United Kingdom byHM’s Inspector of Anatomy. He/she func-tioned across the United Kingdom to ensurecompliance with the Anatomy Act and to dis-seminate good practice. The duties of theInspector of Anatomy were several. He/shemade the recommendation to approve thelicensing of premises for anatomical examina-tion and the licensing of teachers themselves.He/she maintained records of licensed premis-es and teachers and of the bodies within thepremises and of their disposal. He/she visitedpremises annually to ensure they were proper-ly maintained and continued to be suitableand to ensure that proper records were keptand that the anatomical specimens and cadav-ers were maintained in a good state, that partswere retained in accordance with the law andthat proper arrangements for consent were inplace.

Arrangements for communicating withpotential donors wishing to donate their bod-ies, registering donations and accepting thebody after death varied in detail between dif-ferent departments of anatomy, but the same


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general approach was adopted throughout. AtCardiff, the response to an initial enquiry wasto send out a note explaining the process todonors, describing the uses to which the bodywould be put, and the length of time up towhich the body would be retained. Donorswere informed that the department did notguarantee to accept bequests. Donors werealso asked to discuss their wishes with theirnext of kin and place a written statement ofintent with their papers (e.g. legal will andtestament). Donors were also advised thatcosts of transport to the department upondecease would only be paid if the place ofdeath was less than 50 miles from Cardiff andthat the School would meet the costs of dis-posal. While, under the Anatomy Act, donorswere not required to sign any legally bindingform, they were asked to complete a form andreturn it to the department signifying theirintentions. Upon decease, when the depart-ment had been informed, information wassought from the doctor and a decision takenwhether or not to accept the body. Refusal toaccept a body could be based upon health andsafety considerations (e.g. history of dementiaor certain other neurological pathologies,infections such as MRSA, and hepatitis) orbecause the history of disease rendered the useof the body impractical (e.g. autopsy, trans-plantations, cachexia, major surgical interven-tions) or because the body was not suitable foruse in the dissecting room (e.g. over or underweight bodies; numbers surplus to require-ments). If the decision was to accept the dona-tion then the undertakers were informed andgiven a form that the relatives had to completeconfirming the intentions of the deceased andsigning a statement about whether or not thedeceased would have wished any parts to beretained. Once the Medical Certificate ofDeath was also received then the body couldbe accepted. At this point, the Inspector ofAnatomy was also notified. At the end of theperiod during which the body was retained,the department made arrangements for dis-posal by cremation (or sometimes burial). Therelatives were informed. Parts of the bodycould only be retained beyond this time byexpress consent of the donor. Relatives wereinvited to the committal service, although inpractice few chose to attend. However, as formost other departments in the United King-dom, an annual “memorial service of thanks-giving” was conducted to thank the donors forthe gift of their bodies for teaching and

research. For this event, relatives of the donorsand staff and students were invited to attend.

Although the Anatomy Act had been inforce, and had worked well, for over 100 years,in 2004 a new Act was passed in the UKcalled the Human Tissues Act. The introduc-tion of this Act was prompted by a series ofissues relating to the retention of pathologicalmaterial and, while anatomy departments hadcontinued to operate well under existing leg-islation, it was felt by Government and itsCivil Service that a single unifying legislativeframework was required. This view wasopposed by anatomists who would have pre-ferred to retain the Anatomy Act. At the pres-ent time, the operation of the Human TissueAct is being overseen by a Human TissuesAuthority who has drafted a Code of Practiceto regulate activities of anatomy andanatomists under the Human Tissues Act. TheHuman Tissues Authority also manages anInspectorate. Many operational details arebeing resolved, but it is not possible to give afull account of the new arrangements at thisstage.

Nevertheless, important differencesbetween the Anatomy Acts and the HumanTissue Act are discernible:1. The Human Tissues Act covers all dona-

tions of human tissues (including materialfor transplantation and pathology and tis-sues banks) – it therefore regards anatomyas a smallish part of its remit which is oflow risk because of the history of inspec-tions under longstanding legal frame-works. It is likely that the contribution ofanatomists to the activities of the HumanTissues Authority will be further dimin-ished when that authority is merged in thenear future with the Human Embryologyand Fertility Authority.

2. There will not be a specific individual likethe HM Inspector of Anatomy but anInspectorate that will have duties relatingto all aspects of the Human Tissues Act(i.e. inspection of tissue banks and patho-logical collections etc).

3. Consent is now explicit within the HumanTissues Act and forms the cardinal princi-ple of the Act. Indeed, this consent mustbe informed consent (so detailed informa-tion for potential donors must now be pro-vided to enable them to come to theirdecisions) and the consent must always bewitnessed.


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4. Each area under the auspices of the HumanTissue Act has its own “Code of Practice”and there is one specifically for anatomicalexamination, storage, and disposal. Over-all, there has been a major increase inpaperwork and bureaucracy and the onlineapplication for licensing is demanding.

5. The electronic forms used to record thereceipt of anatomical bequests are nowmore uniform across the sector in the Unit-ed Kingdom.

6. Standard operating procedures (SOPs) arenow required for all activities relating toanatomy.

7. Export and import of anatomical materialis possible but with defined controllingmeasures.

8. Public display of anatomical material ispossible but requires special licensing andcontrolling measures and images of thematerial in the dissecting room can only betaken with consent of the donor beforedeath.

9. It is now possible to extend the use ofcadavers from simple anatomical examina-tion to the use of material for research andfor surgical training.

10. Anatomical specimens may (with appro-priate consent) be kept beyond the 3 yearlimitation previously set as the normunder the Anatomy Act.

11. The “Licensed Teacher of Anatomy” inthe Anatomy Act has been replaced by a“Designated Individual” and this neednot necessarily be an anatomist.

12. Committees such as a Governance Com-mittee must be set up within anatomydepartments to regulate and manage theactivities associated with anatomy.

13. Costs of licensing have risen markedly.

It should finally be noted that, at the timeof writing (July 2007), the Republic of Ire-land is considering implementing a HumanTissue Act that is in line with that existing inthe United Kingdom. However, discussionsare at a very early stage and there are someworries about some of the provisions of theUK Act, particularly in relation to issuesaround the “inspectorate”.

SUMMARY AND CONCLUSIONS

The purpose of this paper has been toreview practices relating to the donation of

bodies for medical education and research andit stemmed from a meeting of the Trans-Euro-pean Pedagogic Research Group for theanatomical sciences which is a special interestgroup of the European Federation of Experi-mental Morphologists. While we would notclaim to have carried out a complete survey ofpractices in all European countries, we dobelieve that we have surveyed a sufficientbreadth of practice to be confident that mostprocedures in current use are represented. Asthe result of this survey, we feel in a positionto be able to propose a series of recommenda-tions of good practice in relation to the accept-ance, storage and handling and subsequentdisposal donated bodies for anatomical exami-nation.

Therefore, the following points are offeredas a summary of good practice highlighted bythe participants in the meeting relating to thepractical procedures for accepting donations ofbodies and tissues, how those tissues are storedand handled with departments of anatomy, thearrangements made for disposal, together witharrangements for communicating with donorsas from the initial expression and their rela-tives within their own countries. It should beemphasised that no one department or schoolcurrently carries out all the recommendationsdetailed below. However, this summary isoffered in the hope that all these recommenda-tions will be progressively adopted by anato-my departments throughout Europe.

The examination of human cadavericremains has always been one of the founda-tions of anatomical knowledge and education.The importance of this foundation must notbe overlooked amongst the wealth of othertechniques that have been crucial in under-standing human structure. However, theTrans-European Pedagogic Research Groupfor the anatomical sciences remains firmly ofthe opinion that the examination of the dis-sected human cadaver should be retained as acornerstone of anatomical education and offersthese recommendations to ensure that donorswill continue to display their courage andgenerosity in donating their bodies for med-ical education and research after their death. Ifsuch donations are to continue to be receivedin the numbers that they traditionally havebeen, then donors need to have absolute confi-dence in the departments accepting bequests.These recommendations are compiled to assistin ensuring that departments of anatomy con-tinue to maintain the very highest standards


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of conduct that they have demonstrated in therecent past. We all need to be mindful of thefact that anatomy is a fragile discipline thatwould be difficult to reconstitute if damagedor destroyed by any unethical practice aspresently perceived by European society.

RECOMMENDATIONS OF GOOD PRACTICE FORTHE DONATION OF HUMAN BODIES AND TIS-SUES FOR ANATOMICAL EXAMINATION

1. A clear and rigorous legal frameworkshould be established that sets out the proce-dures to be followed in accepting bequests ofhuman remains for anatomical examination,the safe care and storage of human remainswithin departments, and their disposal oncethe anatomical examination is complete andthey are no longer required for anatomicaleducation and research. This legal frameworkshould also detail who is responsible forbequested human remains once the donationhas been accepted and should specify thelength of time for which such remains will beretained by the department or school thataccepts them. Any legal framework shouldmake specific reference to the particular issuesthat relate to the bequest of human remainsfor anatomical education and research. A goodlegal framework will ensure that donors havefull confidence in the procedures, and so islikely to increase donations.2. Informed consent from donors should beobtained before any bequest can be accepted.3. Donors who have bequeathed their bodiesfor the purposes of anatomical teaching andresearch should be encouraged, wherever pos-sible, to discuss their intentions with their rel-atives to ensure both that their relatives areclear about their wishes and that their rela-tives can carry out those wishes expressed inlife, after death.4. All bequests from donors should be madein writing, with copies retained both by thedonor and by the department for whom thebequest is intended.5. Donors and their relatives need to be clearabout the possible costs, if any, that might beincurred in making a bequest and those coststhat they can expect to be met by the depart-ment accepting the bequest.6. There needs to be transparency of proce-dures relating to how bequests from potentialdonors will be registered, the procedures to be

followed after death (including under whatcircumstances a bequest might be declined),and the procedures relating to disposal of thehuman remains. Sufficient grounds for rejec-tion could include, but need not be limited to,the physical condition of the body, the viro-logical or microbiological status of the donorin life, the existence of other diseases, (forexample neurological pathology) that mightexpose staff or students handling the body tounacceptable risks, or the possible over-supplyof donations at a department at that particularmoment.

7. There needs to be clarity about the pur-poses for which cadavers accepted by depart-ments are being used.

8. Good conservation procedures should beemployed throughout the entire period dur-ing which the human remains are retainedwithin departments to ensure that the mosteffective use is made of any bequest received.

9. Donor anonymity should be preservedthroughout the period for which remains areretained within departments, though thereshould be adequate record keeping to ensureany parts can be identified as originating froma specific donor.

10. There needs to be openness with thedonors at every stage from the receipt of aninitial enquiry to the final disposal of theremains once they are no longer required bythe department.

11. Departments of anatomy, or the medicalschools of which they are a part, should pro-duce an information leaflet for potentialdonors and their relatives that sets out clearlythe procedures for bequeathing bodies foranatomical teaching and the purposes forwhich such bequests are accepted as outlinedin points 2-8 above.

12. Donors should be issued with donor cardsonce the initial intention to bequeath has beenrecorded and they should be encouraged tocarry these cards with them at all times so thattheir intentions expressed in life can be con-firmed after death.

13. Medical schools or anatomy departmentsshould be encouraged to hold Services ofThanksgiving or Commemoration for thosewho have donated their bodies for medicaleducation and research to which can be invit-ed, relatives of the deceased, staff and stu-dents.


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14. Relatives of the deceased should beinformed well in advance of the date of com-mittal of the body of the deceased and invitedto that committal service.

15. There needs to be an urgent movetowards the establishment of internationaltreaties to regulate the transport of humanbodies, or body parts, across national or inter-national borders.

16. Special lectures in ethics relating to thebequest of human remains should be offered toall students studying anatomy to encouragethe development of appropriate sensitivities inrelation to the conduct and respect that isexpected in relation to handling humanremains used for purposes of professionalanatomical education.

17. There should be no commercialisation inrelation to bequests of human remains foranatomical education and research.

18. Limits need to be placed on the extent towhich images, or other artefacts producedfrom donations are placed in the publicdomain, both to respect the privacy of thedonor (and their surviving relative) and to pre-vent arousing morbid curiosity.

19. A pre-donation leaflet that sets out theprocedures to be followed should be producedas one way of publicising anatomical bequestsand increasing the supply of donors.Anatomists should thus be prepared to adver-

tise and advocate the importance of bodydonation for the advancement of the subjectand of medicine and related disciplines.

ACKNOWLEDGEMENTS

The authors would like to thank the Euro-pean Federation for Experimental Morphologyfor its support in developing the Trans-Euro-pean Pedagogic Research Group for theanatomical sciences. In addition, we are mostgrateful to the University of Paris Descartes(and notably Professor V. Delmas and Dr O.Plaisant) for its hospitality in providing facil-ities and resources for the meetings of theTrans-European Pedagogic Research Groupfor the anatomical sciences.

REFERENCES

BARILAN YM (2006). Body worlds and the ethics of usinghuman remains: a preliminary discussion. Bioethics, 20:233-247.

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SPANISH ANATOMICAL SOCIETY (1996). Acta de Barcelona.Viewable at: Actabarcelona.doc http://www.sociedadanatomica.es/ SAE/Documentos.html


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