The evolving ethics of anatomy: Dissecting an unethical past in order to prepare for a future of ethical anatomical practice

Anatomical practice has arguably one of the most ethically challenging histories in the medical sciences. Among the oldest scientific disciplines in medicine, dissection of the human body for scientific purposes occurred as early as the third century Before the Common Era. Throughout the history of anatomical practice, human dissection has occurred in ways that cross the line from progressing medical science to violating the sanctity of the human body. The dissection of the human body creates ethical dilemmas which stem from the need for anatomical science to gain medical knowledge in juxtaposition with prevailing religious and moral views surrounding anatomy as a threat to the sanctity of the human body. This article examines the unethical history of human dissection throughout the ages and explores the rationale behind the unethical practices. In addition, this article explores imperative modern day ethical standards in anatomy including, the ethical handling of human bodies, respecting human life, and ensuring informed consent for dissection of bodies that are donated. Finally, this article explores the question of which ethical prism we should use when dealing with anatomy collections or works of the past. Learning both the history of unethical practices in anatomy and the rationale behind them is imperative so that the discipline can prepare for an ethical, diverse, and inclusive future. This article provides a foundation for understanding the evolution of ethics in anatomical practice and is a valuable resource for students and anatomists alike.     

The fate of the bodies of executed persons in the Anatomical Institute of Halle between 1933 and 1945

In the period from 1933 to 1945 the Anatomical Institute in Halle (Saale) received bodies of persons, among them politically persecuted women and men, who had been sentenced to death and executed. In this article, we attempt to answer two important questions: (1) What happened to the bodies of those executed; i.e. which anatomical “purposes” did they serve? (2) Were anatomical specimens from these bodies added to the institute’s anatomical collection and are they still present today? If so, can they be traced back to the bodies of politically persecuted people? So far we have discovered that between 1933 and 1936 the institute received 30 bodies, among them the bodies of two politically motivated death sentences. From 1937 until the end of 1942, only a few bodies arrived at the institute, and from November 1942 until the end of the war in 1945 the institute documented the transfer of 64 bodies of executed people. The death sentences pronounced during those early years were usually based on severe criminal acts (e.g. murder). During the war, special courts sentenced people to death mostly because of theft, looting, etc. The bodies of those executed were used in anatomical education, anatomical research, and in preparations of anatomical specimens to be added to the anatomical collection. There are eight macroscopic preparations which can definitely be associated with the bodies of people executed during the Nazi regime. Trial by jury sentenced those people to the maximum penalty because of the severity of their criminal acts. Up to now we have found no evidence that specimens of the anatomical collection were removed from bodies of victims whose execution was politically motivated.     

Anatomical mapping of the nasal muscles and application to cosmetic surgery

We present an anatomical mapping of the most important muscles influencing the nose, incorporating constant anatomical structures, and their spatial correlations. At our disposal were the midfaces of 18 bodies of both sexes, obtained by informed consent from body donors aged between 60 and 80 years. Macroscopically, we dissected the nasal regions of eight corpses, six midfaces were prepared according to plastination histology, four by creating plastinated slices. On their way from their periosteal origin to the edge of the skin, the muscles of the nose cross the subcutaneous adipose tissue, dividing it into superficial and deep layers. The individual muscle fibers insert into the skin directly at the reticular corium. Sometimes, they reach the border of the epidermis which represents a special arrangement of corial muscle attachments. The course of the anatomical fibers of individual nasal muscles presented macroscopically and microscopically in this study offers surgeons a detailed overview of the anatomically important muscular landmarks of the midface. Clin. Anat. 27:1178–1184, 2014. © 2014 Wiley Periodicals, Inc.     

Anatomical eponyms,part 1: To look on the bright side

The use of eponyms in medical sciences generally, and in anatomy specifically, remains controversial. In principle, this discussion should have been concluded as far back as 1895 (publication of the first Nomina anatomica): all eponyms should have been removed from the anatomical vocabulary then. In practice, what was believed to be a mere formality proved much more difficult to apply. Most eponyms remain in current use; moreover, their number goes on increasing. Assuming that there's no smoke without fire, we wondered why it seems impossible to get rid of a specific kind of term. The aim of this article and its successor is to weigh up the pros and cons. Clin. Anat. 27:1142–1144, 2014. © 2014 Wiley Periodicals, Inc.     

Using rhetorical theory in medical ethics cases

In this paper I argue that rhetorical theory is a valuable tool in medical ethics cases. The case I use as an example is one in which traditional, philosophy-based medical ethics are applied. In this case the traditional ethical approach is not adequate to the task. Key issues and problems are not addressed, resulting in a problem that seems to be solved on the surface, but, when rhetorically analyzed, it's obvious that none of the issues have been resolved in any satisfactory way. By using rhetorical theory, such as that Michel Foucault uses in Power/Knowledge, we discover that the reason this case has not been solved is that the power issues have not been addressed. Using Foucault's concepts of "subjugated knowledge", "local knowledge", "situated knowledge", and "docile bodies", we can tease out the real issues that surface in this ethics case and solve them. Foucault also recommends we use theory as a "toolkit". I propose a model that is a further iteration of this idea. My model uses numerous rhetorical and literary theories, depending on the issues that need to be addressed in each individual medical ethics case. I briefly describe the various theories and include a handout of what the new model of using rhetorical theory in such cases would look like.     

Current status of identification of victims of the National Socialist regime whose bodies were used for anatomical purposes

Research on the history of anatomy in the Third Reich has often focused on anatomists who collaborated with the National Socialist (NS) regime. Only recently has attention shifted to investigations of the victims, of which there are two groups: anatomists whose careers were disrupted by NS policies, and victims of the NS regime whose bodies were used for anatomical purposes. No systematic approach has yet been undertaken toward the identification of all the different groups of victims and the individuals' fates. This overview of currently available data on NS victims whose bodies were used for anatomical purposes reveals that an estimated total number of all bodies delivered to departments of anatomy lies at more than 40,000, and the so far documented number of executed persons among them at a minimum of 3,749. The traditional sources of body procurement and their significant changes in character during the NS period can be traced. Postwar attempts on finding the fate and identity of bodies of NS victims in anatomy can be divided into three phases. Most investigations focused on the removal of remaining “material” from NS victims from the anatomical collections, while identification and remembrance of individual victims was not a priority. So far, about 500 NS victims' names and biographies have been at least partially identified. Existing memorials rarely name individuals. New approaches to the identification of victims and the potential of a databank for these victims' biographies as an appropriate manner of remembrance are examined in this study. Clin. Anat. 514–536, 2014. © 2013 Wiley Periodicals, Inc.     

Consensus guidelines for the uniform reporting of study ethics in anatomical research within the framework of the anatomical quality assurance (AQUA) checklist

Unambiguous reporting of a study's compliance with ethical guidelines in anatomical research is imperative. As such, clear, universal, and uniform reporting guidelines for study ethics are essential. In 2016, the International Evidence‐Based Anatomy Working group in collaboration with international partners established reporting guidelines for anatomical studies, the Anatomical Quality Assurance (AQUA) Checklist. In this elaboration of the AQUA Checklist, consensus guidelines for reporting study ethics in anatomical studies are provided with in the framework of the AQUA Checklist. The new guidelines are aimed to be applicable to research across the spectrum of the anatomical sciences, including studies on both living and deceased donors. The authors hope the established guidelines will improve ethical compliance and reporting in anatomical research. Clin. Anat. 31:521–524, 2018. © 2018 Wiley Periodicals, Inc.     

The affirmation of self: a new perspective on the immune system

The fundamental concepts of autopoiesis, which emphasize the circular organization underlying both living organisms and cognition, have been criticized on the grounds that since they are conceived as a tight logical chain of definitions and implications, it is often not clear whether they are indeed a scientific theory or rather just a potential scientific vocabulary of doubtful utility to working scientists. This article presents the deployment of the concepts of autopoiesis in the field of immunology, a discipline where working biologists themselves spontaneously have long had recourse to "cognitive" metaphors: "recognition"; a "repertoire" of recognized molecular shapes; "learning" and "memory"; and, most striking of all, a "self versus non-self" distinction. It is shown that in immunology, the concepts of autopoiesis can be employed to generate clear novel hypotheses, models demonstrating these ideas, testable predictions, and novel therapeutic procedures. Epistemologically, it is shown that the self-non-self distinction, while quite real, is misleadingly named. When a real mechanism for generating this distinction is identified, it appears that the actual operational distinction is between (a) a sufficiently numerous set of initial antigens, present from the start of ontogeny, in conditions that allow for their participation in the construction of the system's organization and operation, and (b) single antigens that are first presented to the system after two successive phases of maturation. To call this a self-non-self distinction obscures the issue by presupposing what it ought to be the job of scientific investigation to explain.     

Books,bones and bodies: The relevance of the history of anatomy in Nazi Germany for medical education today

The history of anatomy in Nazi Germany highlights the consequences to humanity when the destructive potentials immanent to all science and medicine are enabled by an anti-democratic, totalitarian regime. Anatomy presents an example of ethical transgressions by scientists and health care professionals that were amplified in the criminal political climate of the Nazi regime. This can happen anywhere, as science is never apolitical. This article gives a short account of anatomy in Nazi Germany, which is followed by an outline of the tangible and intangible legacies from this history, to then discuss implications for anatomy education today. While Jewish and politically dissident anatomists were forced out of their positions and country by the Nazi regime, the majority of the remaining anatomists joined the Nazi party and used bodies of Nazi victims for education and research. Some anatomists even performed deadly human experiments. Patterns and legacies that emerge from this history can be traced into the present and concern research ethics in general and anatomical body procurement specifically. They shed light on current practices and controversies in the anatomical sciences, including anthropology. It will be argued here that the history of anatomy in Nazi Germany can inform current anatomy education in a concept of anatomy as the first “clinical discipline.” By integrating insights from the history of anatomy into the learning process, anatomy education can model an approach to medicine that includes a full appreciation of the shared humanity of medical practitioners and patients.     

What is happening in our anatomical dissection rooms?

A recent student article relates disrespectful and traumatizing events in a modern dissection room. This comment serves to remind anatomical educators' of their duties toward the medical students. It is the anatomical educators' duty to help students not only to become familiar with the structure of the human body but also with the emotional repertoire available when dealing with the living and the dead. And it is the educators' duty to accompany students through the dissection course experience in a manner that keeps them safe from emotional harm. Clin. Anat. 27:833–834, 2014. © 2014 Wiley Periodicals, Inc.     

Using and respecting the dead human body: An anatomist's perspective

In his stimulating article enquiring into what the living owe the dead, Wilkinson (2013, Clin. Anat. DOI: 10.1002/ca.22263 ) sought to unpack a range of ethical questions of considerable interest to anatomists. In this, he looked closely at the extent to which we are or are not to respect all the prior wishes of the deceased, and the implications of this for the role of the family in providing consent, the use of unclaimed bodies, and the public display of bodies. Some of his conclusions challenge widely encountered views by anatomists. In this response I have re‐visited these topics in an attempt to ground his arguments in the experience of anatomists, by emphasizing the many intimate connections that exist between each of these areas. The following emerge as issues for further debate. I accept that the wishes of the deceased are preeminent, so that authorities should make every effort to abide by these. This reiterates the importance of body bequests over against unclaimed bodies, and provides a context for assessing the role of family consent. This has repercussions for all activities employing dead bodies, from the dissecting room to public plastination exhibitions. In determining the extent to which the wishes of the deceased are followed the input of other interested parties is a relevant consideration. An ethical assessment of the public display of bodies needs to take into account the nature of the plastination process. Clin. Anat. 27:839–843, 2014. © 2014 Wiley Periodicals, Inc.     

Responsibly managing the medical school--teaching hospital power relationship.

The relationship between medical schools and their teaching hospitals involves a complex and variable mixture of monopoly and monopsony power, which has not been previously been ethically analyzed. As a consequence, there is currently no ethical framework to guide leaders of both institutions in the responsible management of this complex power relationship. The authors define these two forms of power and, using economic concepts, analyze the nature of such power in the medical school-teaching hospital relationship, emphasizing the potential for exploitation. Using concepts from both business ethics and medical ethics, the authors analyze the nature of transparency and co-fiduciary responsibility in this relationship. On the basis of both rational self-interest, drawn from business ethics, and co-fiduciary responsibility, drawn from medical ethics, they argue for the centrality of transparency in the medical school-teaching hospital relationship. Understanding the ethics of monopoly and monopsony power is essential for the responsible management of the complex relationship between medical schools and their teaching hospitals and can assist the leadership of academic health centers in carrying out one of their major responsibilities: to prevent the exploitation of monopoly power and monopsony power in this relationship.     

数字化全牙列下颌骨三维解剖建模

目的探讨建立具有高质量牙列的下颌骨三维数字化解剖模型。方法用激光扫描获取1套标准下颌牙列解剖标本的精确三维模型,用CT扫描数据重建下颌骨三维模型,使用基于几何和图像解剖标志的配准变形方法将每颗牙齿模型对齐融合到下颌骨模型,进一步生成牙齿的牙釉质、牙本质、牙周膜。结果成功建立了具有高质量牙列的下颌骨三维数字化解剖模型,每颗牙齿具有牙冠细节和完整的牙根,区分牙釉质、牙本质、牙周膜,可以对任意解剖区域放大和旋转观察,显示解剖标志。结论高质量牙列的下颌骨三维数字化解剖模型具有逼真的三维显象和方便的教学学习功能,可用于口腔、颌面、解剖等多个学科。     

Anatomy in the Third Reich: an outline,part 3. The science and ethics of anatomy in National Socialist Germany and postwar consequences

Anatomists in National Socialist (NS) Germany did research on materials from animals and humans, including tissues from the bodies of NS victims. The research was competent but rarely innovative. This may be due to the isolation of the German research community from international developments, as well as to the dismissal of a great number of successful anatomists for racial or political reasons. Other research was unproductive because of its foundation in the pseudoscience of racial hygiene. Anatomists in the Third Reich acted according to a new set of medical ethics favored by the NS regime. Not the individual human being but the “body of the people” as a whole was the object of this ethics. Every action was ethical that ensured the health of the German people, including sterilization, so‐called euthanasia, and finally mass murder. Anatomists made use of the opportunities given to them by the NS regime, which led to the postmortem utilization of the bodies of NS victims. After the war, most anatomists retained their positions and NS history was not discussed until the later 20th century. Since then, historical research and public discussions have led to an increased awareness of questions of ethics in anatomy. The history of anatomy in the Third Reich illustrates that the theory and practice of a science is dependent on the political system it exists in, and that the scientists' competence not only in their science but also in politics and ethics is a prerequisite for the freedom of science. Clin. Anat. 22:906–915, 2009. © 2009 Wiley‐Liss, Inc.     

Psychotherapy and Moralising Rhetoric in Galen’s Newly Discovered Avoiding Distress (Peri Alypias)

In this article, I examine Galen’s credentials as an ethical philosopher on the basis of his recently discovered essay Avoiding Distress (Peri alypias). As compensation for the scholarly neglect from which Galen’s ethics suffers, I argue that his moral agenda is an essential part of his philosophical discourse, one that situates him firmly within the tradition of practical ethics of the Roman period. Galen’s engagement with Stoic psychotherapy and the Platonic-Aristotelian educational model affirms his ethical authority; on the other hand, his distinctive moralising features such as the autobiographical perspective of his narrative and the intimacy between author and addressee render his Avoiding Distress exceptional among other essays, Greek or Latin, treating anxiety. Additionally, I show that Galen’s self-projection as a therapist of the emotions corresponds to his role as a practising physician, especially as regards the construction of authority, the efficacy of his therapy and the importance of personal experience as attested in his medical accounts. Finally, the diligence with which Galen retextures his moral advice in his On the Affections and Errors of the Soul – a work of different nature and intent in relation to Avoiding Distress – is a testimony to the dynamics of his ethics and more widely to his philosophical medicine.

The philosopher’s lecture room is a ‘hospital’: you ought not to walk out of it in a state of pleasure, but in pain; for you are not in good condition when you arrive. Epictetus, Discourses 3.23.30

     

A Glimpse into the process of gaining permission for the educational dissection of human cadavers in the Ottoman empire

Dissection of the human body for educational purposes became officially permitted in the Ottoman Empire only after a long, difficult process. In the West, studies based on the findings of Galen had been taboo during a long period in which dissection of human bodies had been prohibited. Although the first dissection studies since ancient times began to appear in the Western literature in the late 13th and early 14th centuries, the post‐Galen taboo against dissection was broken only in the 16th century by the studies of Vesalius. However, in the Eastern World, it was only fairly recently that the idea of the “sanctity of the human body” could be challenged. In the medieval Islamic world, as during the Middle Ages in the West, prohibitions against the dissection of human cadavers continued for social and religious reasons, although the Koran does not specifically ban such dissection. This prohibition also continued through the Ottoman era, which began in the 14th century. The first efforts to end the prohibition on dissection in the Ottoman Empire were made at the beginning of the 19th century during the reign of Sultan Selim III but official permission for dissection was given only in 1841 during the reign of Sultan Abdulmecid. Educational dissections in the Ottoman Empire officially began at the Istanbul Medical School following the granting of this permission. This article will discuss the attempts to end the prohibition of dissection in Ottomans within the scope of the history of anatomical study in Turkey. Clin. Anat. 27:964–971, 2014. © 2014 Wiley Periodicals, Inc.     

生物医学前沿中的伦理问题

本文在讨论科学技术与伦理学关系、生命伦理学基本原则以及道德与伦理学之间的异同后,探讨了人的克隆和干细胞研究、基因治疗、生殖遗传学、异种移植、生物医学和临床研究中的伦理问题。     

The ethics of caring and medical education.

The ethics of caring, though the subject of much recent discussion by philosophers, has hardly been applied to medical ethics and medical education. Based on receptivity (that is, empathy and compassion) toward and taking responsibility for other persons, the ethics of caring has particular relevance to medicine. Caring guides the physician always to remain the patient's advocate and to maintain the therapeutic relationship when dealing with and resolving ethical dilemmas. This article discusses the philosophy behind the ethics of caring and then explores three issues that arise within its context: receptivity, taking responsibility, and creating an educational environment that fosters caring.     

Anatomical Variations in the Aortic Bifurcation in New Zealand White Rabbits on Arteriography

The radiologic anatomy of the aortic bifurcation in the rabbit has received little study but it is important as this anatomical area is widely used in atherosclerosis research. Thirty rabbits were used to study the aortic bifurcation and subsequent branching patterns on arteriography. Fifteen different arteries were identified. Mean arterial diameters of 2.88 ± 0.7 and 2.27 ± 0.55 mm were obtained for the aorta and external iliac arteries, respectively. The cranial and middle aspects at the seventh lumbar vertebra (L7) were the most frequent anatomical landmarks (53.3% of the cases) for aortic and common iliac bifurcations, respectively. The caudal aspect of L6 was the most frequent origin (50% of the cases) for the median sacral artery. Deep circumflex iliac arteries originated from common iliac arteries and not the abdominal aorta in the rabbit, showing anatomical asymmetry in 73.3% of the cases. No gender disparity was found in the anatomical location of any of the arteries of the study. Knowledge of normal vascular landmarks for the aortic bifurcation as well as anatomical variations should be helpful to future experimental studies. Anat Rec, 297:663–669, 2014. © 2014 Wiley Periodicals, Inc.