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.     

New views of male pelvic anatomy: role of computer-generated 3D images

There is considerable controversy concerning the role of cadaveric dissection in teaching gross anatomy and the potential of using 3D computer-generated images to substitute for actual laboratory dissections. There are currently few high-quality 3D virtual models of anatomy available to evaluate the utility of computer-generated images. Existing 3D models are frequently of structures that are easily examined in three dimensions by removal from the cadaver, i.e., the heart, skull, and brain. We have focused on developing a 3D model of the pelvis, a region that is conceptually difficult and relatively inaccessible for student dissection. We feel students will benefit tremendously from 3D views of the pelvic anatomy. We generated 3D models of the male pelvic anatomy from hand-segmented color Visible Human Male cryosection data, reconstructed and visualized by Columbia University's in-house 3D Vesalius trade mark Visualizer.(1) These 3D models depict the anatomy of the region in a realistic true-to-life color and texture. They can be used to create 3D anatomical scenes, with arbitrary complexity, where the component anatomical structures are displayed in correct 3D anatomical relationships. Moreover, a sequence of 3D scenes can be defined to simulate actual dissection. Structures can be added in a layered sequence from the bony framework to build from the "inside-out" or disassembled much like a true laboratory dissection from the "outside-in." These 3D reconstructed anatomical models can provide views of the structures from new perspectives and have the potential to improve understanding of the anatomical relationships of the pelvic region (http://www.cellbiology.lsuhsc.edu/People/Faculty/Venuti_Figures/movie_index.html).     

The utilization of cross-sectional anatomy in a surgical residency training program

The education of students and residents in a surgical department involves a thorough knowledge of three-dimensional anatomical relationships in the body. In addition, the advances in new imaging modalities demand an in-depth study of cross-sectional anatomy by both students and residents. Traditionally, surgical training incorporated dissections of cadavers and the progressive involvement of the resident in the surgical theater. At the King/Drew Medical Center cross-sectional anatomy has been incorporated into the teaching program. The central focus of this instructional program utilizes problem-solving learning modules that emphasize important surgical and anatomical principles.     

Medical students' responses to the dissection of the heart and brain: A dialogue on the seat of the soul

The search for the soul has been documented since the fifth Century BCE when philosophers and physicians began to explore the role of human consciousness and emotion. Traditionally in western civilization, there have been two distinct followings with some believing that the brain was the seat of the soul and others believing that this role belonged to the heart. The aim of this study was to assess the attitudes of medical students towards the heart and brain during their anatomy laboratory dissections to evaluate if any extra meaning is given to these organs and where they perceived the origin of the soul. Medical students (n = 16) at the University of Otago were interviewed in regards to their thoughts about body dissection and particularly their views towards the brain and the heart. Semi-structured interviews were conducted following the dissection of these two organs, and then transcribed and analyzed. There were mixed opinions among students with some experiencing difficulty dissecting the brain because this organ had special meaning to them; they perceived it as the organ that "made a person who they were." Others commented on their emotional reactions when removing the heart, which they viewed as the "seat of emotion." Some students experienced emotional and physical reactions to these two dissections and Anatomy faculty need to be aware that students may struggle because they viewed these organs as special. A dialogue emerged amongst some medical students on the seat of the soul which gave extra meaning to the dissection.     

Gross anatomy dissections and self-directed learning in medicine

The Medical School of the University of Castilla-La Mancha (UCLM, Albacete Spain) was launched in 1998 and is the most recent one in Spain. Teaching is based on small groups of students (20-25 students/group). An objective-oriented self-learning approach provides maximal autonomy and independence in the achievement of objectives by the students in close association with academic staff. Gross Anatomy courses take place in the first and second years. The one in the first year is a single 10-credit course, where one credit equals 10 hr of teaching activity. In the second year, Anatomy and Embryology are integrated with Physiology and Histology, and comprise 70 credits altogether. In addition, all students carry out two mandatory gross anatomical dissections per year, in groups of three students, to allow direct handling of human anatomical material. Students are provided with handouts containing general instructions on how to perform the dissection and the structures (items) that they must expose in a given period of time (4 hr). Afterward, a Faculty member checks the number of items demonstrated and the quality of the dissection. Each group submits a written report that contributes to the final score. We evaluated the number of items shown in each of two consecutive dissections for first and second year medical students. The data obtained indicate that students engaged in self-directed learning through small groups working with Faculty staff are able to self-improve their anatomical skills.     

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.     

Plastination and its importance in teaching anatomy. Critical points for long-term preservation of human tissue

Most medical curricula rely on human bodies for teaching macroscopic anatomy. Over the past 20 years, plastination has become an important means of preservation of organs, for well dissected specimens or for body slices. Here, several critical points regarding body donation with legal and ethical considerations for long-term preservation, the use of cadavers in teaching and the preparation of plastinates as an additional teaching tool will be discussed. Silicone S10 is the gold standard in the preparation of plastinates. An important point to respect is the preparation of specimens, since only very well dissected body parts or excellent tissue sections should be plastinated to show the extraordinary aspects of the human anatomy. The preparation of thin and transparent sections and preservation with P40 polyester provides an additional technique to prepare resistant body slices. A selection of samples prepared by S10 and P40 are shown and compared. In addition, Prussian or Berlin blue staining of brain slices is shown to discriminate better between gray and white matter and demonstrate neuroanatomical structures. These plastinates have been used for many years in teaching first-and second-year medical students and have not lost their appeal. Students and staff appreciate the use of such plastinates. One of the advantages is that their use is not restricted to the dissection hall; slices and body parts can be used in any lecture room or in small group teaching. Therefore, ethical and legal questions need to be addressed regarding their specific use. Plastinates do not replace the traditional dissection courses, since students learn best the anatomical features of a given region by hands-on dissection and by exploratory anatomy. Furthermore, plastinates are more rigid and do not allow demonstration of hidden structures; they also become more cumbersome for endoscopy or are too rigid for demonstrating mechanical features of joints. However, although not a replacement for traditional dissections, plastination provides an additional tool for long-term preservation and for teaching human anatomy.     

Anxiety and dissection of the human cadaver: an unsolvable relationship?

Anxiety is an emotional reaction frequently shown by students when a human cadaver is being dissected. Nonetheless, few studies analyze the nature of the anxiety response in this situation and the ones that do exist are mainly limited to English-speaking countries. Our research has three aims: to study the characteristic anxiety reaction to dissection practices, to determine the weight exerted by internal and environmental variables on this anxiety reaction, and to design practices aimed at reducing the state of anxiety experienced by pupils in their human anatomy practices. The studies were carried out in the dissection room of the Department of Human Anatomy and Embryology II at the Faculty of Medicine of the Complutense University, Madrid, during the 3 academic years 2000-2003. The anxiety response to the first dissection of a human cadaver is mainly determined by a situation considered to be threatening, with novelty as its main characteristic. The students' anxiety response is first determined by the situation itself and reactions depend on individual differences. Repeated or gradual exposure (detailed verbal information on the situation, visits to dissecting rooms when no cadaver is present, videos showing pictures of human dissections, etc.) before carrying out the first dissection reduce the students' anxiety response.     

Do we need dissection in an integrated problem-based learning medical course? Perceptions of first- and second-year students

BACKGROUND: The introduction of a problem-based learning (PBL) curriculum at the School of Medicine of the University of Melbourne has necessitated a reduction in the number of lectures and limited the use of dissection in teaching anatomy. In the new curriculum, students learn the anatomy of different body systems using PBL tutorials, practical classes, pre-dissected specimens, computer-aided learning multimedia and a few dissection classes. The aims of this study are: (1) to assess the views of first- and second-year medical students on the importance of dissection in learning about the anatomy, (2) to assess if students' views have been affected by demographic variables such as gender, academic background and being a local or an international student, and (3) to assess which educational tools helped them most in learning the anatomy and whether dissection sessions have helped them in better understanding anatomy. METHODS: First- and second-year students enrolled in the medical course participated in this study. Students were asked to fill out a 5-point Likert scale questionnaire. Data was analysed using Mann-Whitney's U test, Wilcoxon's signed-ranks or the calculation of the Chi-square value. RESULTS: The response rates were 89% for both first- and second-year students. Compared to second-year students, first-year students perceived dissection to be important for deep understanding of anatomy (P < 0.001), making learning interesting (P < 0.001) and introducing them to emergency procedures (P < 0.001). Further, they preferred dissection over any other approach (P < 0.001). First-year students ranked dissection (44%), textbooks (23%), computer-aided learning (CAL), multimedia (10%), self-directed learning (6%) and lectures (5%) as the most valuable resources for learning anatomy, whereas second-year students found textbooks (38%), dissection (18%), pre-dissected specimens (11%), self-directed learning (9%), lectures (7%) and CAL programs (7%) as most useful. Neither of the groups showed a significant preference for pre-dissected specimens, CAL multimedia or lectures over dissection. CONCLUSIONS: Both first- and second-year students, regardless of their gender, academic background, or citizenship felt that the time devoted to dissection classes were not adequate. Students agreed that dissection deepened their understanding of anatomical structures, provided them with a three-dimensional perspective of structures and helped them recall what they learnt. Although their perception about the importance of dissection changed as they progressed in the course, good anatomy textbooks were perceived as an excellent resource for learning anatomy. Interestingly, innovations used in teaching anatomy, such as interactive multimedia resources, have not replaced students' perceptions about the importance of dissection.     

The anatomic tradition in Venice

Venice had a long tradition and great reputation in the study of anatomical science dating back to the 1300's. The "Serenissima" Republic favoured the study and practice of anatomy as part of medical professional formation. Before the construction of the anatomical theater of San Giacomo dell'Orio, which took place in 1671, anatomical dissections were performed in churches, convents, hospitals and private homes. Even though Venice was not a University seat, it boosted numerous Venetian anatomists, among whom Benedetti, Massa, Santorini, and the medical activity of illustrious professors at the nearby University of Padua such as Vesalio, Falloppio, Spigelio, Vislingio and Morgagni.     

Dissection from the Spanish anatomist's perspective: aims, attitudes, and related aspects

We present the results of a study conducted on participants of the 21st Congress of the Spanish Society of Anatomy, in which anatomists were asked their opinions about a range of issues related to anatomical dissection: its relative roles as the exclusive source of anatomy teaching, as a source for medical research, or to assist the future professional to acquire emotional control; the attitudes and behaviors they expect the student to have in the dissecting room; whether the student-cadaver relationship can convey knowledge and attitudes affecting the future doctor-patient relationship; and the anatomists' attitudes toward donation. Anatomists considered dissection to be mainly an instrument for professional training and to help develop professional skills. They gave little importance to the role it could play in helping students to control their emotions. However, this aspect was considered to be more important by anatomists who also valued a close doctor-patient relationship. On the other hand, a majority of anatomists felt that the student's attitude and behavior during dissection could be to some extent reflected in future relationships with patients. However, they did not feel that dissection-related attitudes would distinguish between future good or bad doctors. Finally, anatomy teachers are generally in favor of donation (86.5%), especially of organs alone (52.7%), and this aspect was not affected by their religious beliefs.     

The dissection course – necessary and indispensable for teaching anatomy to medical students

Anatomy is a major basic subject in medicine and related biomedical sciences. A central tool most universities use for teaching anatomy is the “dissection course”, in which medical students learn the basic constructional principles of the human body by dissecting a cadaver. In recent years, the relevance and value of the dissection laboratory have been under discussion at different universities due to high costs and problems of shortness in time in some medical curricula. Indeed, during the last 10 years, several universities in the US and the UK have abandoned dissection and have moved from a cadaver-oriented to a cadaverless anatomy. This development results in a fundamental discussion on the role of the “dissection course” in the medical curriculum, ultimately raising the question as to whether we should continue teaching anatomy by dissection. This article presents nine arguments for the dissection course as a central tool for teaching macroscopic anatomy and is an attestment to the continuation of the use of cadaver material in anatomical laboratories within the auspices of scholastic and university order for the benefit of future physicians with due respect and honour guaranteed for every donor.     

An interactive three-dimensional virtual body structures system for anatomical training over the internet

The Visible Human digital datasets make it possible to develop computer-based anatomical training systems that use virtual anatomical models (virtual body structures-VBS). Medical schools are combining these virtual training systems and classical anatomy teaching methods that use labeled images and cadaver dissection. In this paper we present a customizable web-based three-dimensional anatomy training system, W3D-VBS. W3D-VBS uses National Library of Medicine's (NLM) Visible Human Male datasets to interactively locate, explore, select, extract, highlight, label, and visualize, realistic 2D (using axial, coronal, and sagittal views) and 3D virtual structures. A real-time self-guided virtual tour of the entire body is designed to provide detailed anatomical information about structures, substructures, and proximal structures. The system thus facilitates learning of visuospatial relationships at a level of detail that may not be possible by any other means. The use of volumetric structures allows for repeated real-time virtual dissections, from any angle, at the convenience of the user. Volumetric (3D) virtual dissections are performed by adding, removing, highlighting, and labeling individual structures (and/or entire anatomical systems). The resultant virtual explorations (consisting of anatomical 2D/3D illustrations and animations), with user selected highlighting colors and label positions, can be saved and used for generating lesson plans and evaluation systems. Tracking users' progress using the evaluation system helps customize the curriculum, making W3D-VBS a powerful learning tool. Our plan is to incorporate other Visible Human segmented datasets, especially datasets with higher resolutions, that make it possible to include finer anatomical structures such as nerves and small vessels.     

Human gross anatomy: A crucial time to encourage respect and compassion in students

We suggest four ways in which human gross anatomy instructors can reinforce respect and compassion in students. First, encourage respectful language in the laboratory. The term “donor” should be used instead of “cadaver” or “corpse” in referring to the donated body because this promotes appreciation for the students' first “patient.” Second, provide the students with the actual name, age, history, and likely cause of death of the donor so that they more fully appreciate the donor as having once been a living human being. Third, prompt students to explore feelings and discuss topics stimulated by the intense experience of human dissection. Suggested topics include the students' feelings about dissecting a human being, the difficulty in deciding to donate one's body, the central importance of anatomy to a medical practitioner's role, and the historical development of the study of anatomy. Fourth, hold a memorial ceremony, in which both students and faculty participate, as a positive closure to an emotionally and intellectually intense course. Additionally, a ceremony reinforces salutary values in students, enhances social bonding among students, and encourages their appreciation of various cultural and religious beliefs. These methods introduce a new dimension of experience for anatomy students. We have developed these methods in response to what we view as a negative trend in the medical profession in which health care becomes technical and patients become objects. It is our role as faculty to reinforce respectful and compassionate attitudes in medical students from the very beginning. © 1995 WiIey-Liss, Inc.     

The use of plastinated prosections for teaching anatomy--the view of medical students on the value of this learning resource

Over the past decade, the role of anatomical teaching in the undergraduate medical curriculum has changed considerably. At some medical schools, active dissection of cadaveric specimens is gradually being replaced by prosection-based methods and other resources such as e-learning. Warwick Medical School has recently obtained a large collection of plastinated prosections, which replace wet cadaveric specimens in undergraduate anatomy teaching. The aim of this study was to examine students' views on the use of plastinated prosections for their anatomical learning. A mixed method approach was employed using a questionnaire and focus group for data collection. The questionnaire was completed by 125 first-year medical students (response rate 68%). The majority of students (94%) rated plastinated prosections as a valuable resource for their anatomical learning. Various features of the specimens were highlighted, such as the detailed view of relevant anatomy, appreciation of relations between structures, and visualization of anatomy in real life. However, learning on plastinated prosections was perceived to be compromised because of limitations in terms of tactile and emotional experience. We conclude that plastinated prosections are an adequate resource for the early stages of undergraduate training, but that the learning experience may be further enhanced by providing opportunity for the study of wet cadaveric material.     

The evolution of epistemological methodologies in anatomy: From antiquity to modern times

Present day scenario regarding epistemological methods in anatomy is in sharp contrast to the situation during ancient period. This study aimed to explore the evolution of epistemological methodologies in anatomy across centuries. In ancient times Egyptian embalmers acquired anatomical knowledge from handling human bodies and likewise anatomical studies in India involved human dissection. Ancient Greeks used theological principles-based methods, animal dissection and human dissection in practice of anatomy. Human dissection was also practiced in ancient China for gaining anatomical knowledge. Prohibition of human dissection led to use of animal dissection in ancient Rome and the trend continued in Europe through Middle Ages. Epistemological methods used by Muslim scholars during Middle Ages are not clearly chronicled. Human dissection returned as primary epistemological method in Renaissance Europe and empirical methods were reinstated after ancient period in human dissection during 16th century. The situation further improved with introduction of pragmatic experiment based approach during 17th century and autopsy-based methods during 18th century. Advances in anatomical knowledge continued with advent of microscope-based methods and emergence of anatomical sections in practice of human dissection in 19th century. Introduction of human observational studies, medical imaging, and molecular methods presented more options in terms of epistemological methods for investigating the human body during 20th century. Onset of 21st century has witnessed dominance of technology-based methods in anatomy. Limited emphasis on ethics in epistemological methodologies since antiquity is a dark aspect of otherwise an eventful evolutionary journey but recent developments are in positive direction.     

Anatomy of the thorax and shoulder girdle displayed by magnetic resonance imaging

In 1971, radiographic anatomy of the human body was added to the gross anatomy course at UCLA. Radiographic contrast studies and plain anatomical displays were formulated into teaching packages for all organ systems. Residents presented each package to first-year medical students in the dissection laboratory to augment the teaching of anatomy. In November 1984, magnetic resonance imaging was instituted in the radiology department. Imaging the chest produced coronal and axial planes which displayed the muscles and soft tissues of the thorax. In 1986, the authors presented their study of MR anatomy of the chest and shoulder girdle to the American Association of Anatomists. The purpose of this presentation is to demonstrate the anatomy of the thorax and shoulder girdle as displayed by magnetic resonance, correlated with regional anatomy, with emphasis on soft tissue structures.     

Are we teaching sufficient anatomy at medical school? The opinions of newly qualified doctors

In recent decades wide-ranging changes have occurred in medical school curricula. Time spent studying gross anatomy has declined amidst controversy as to how, what, and when teaching is best delivered. This reduced emphasis has led to concerns amongst clinicians that a new generation of doctors are leaving medical school with insufficient anatomical knowledge. Previous studies have established that medical students value their anatomy teaching during medical school. None have sought to establish views on the sufficiency of this teaching. We investigate the opinions of newly qualified doctors at a UK medical school and relate these opinions to career intentions and academic performance in the setting of a traditional dissection and prosection-based course. Overall nearly half of respondents believe they received insufficient anatomy teaching. A substantial proportion called for the integration of anatomy teaching throughout the medical school course. Trainees intent on pursuing a surgical career were more likely to believe anatomy teaching was insufficient than those pursuing a nonsurgical career; however, overall there was no statistical difference in relation to the mean for any individual career group. This study adds to the current debates in anatomical sciences education, indicating that overall, regardless of career intentions, new doctors perceive the need for greater emphasis on anatomical teaching.     

Orientation to dissection: Assisting students through the transition

Human dissection continues to be strongly argued for teaching human anatomy to medical students and is technically and emotionally demanding. An orientation to dissection and the laboratory are provided for students before beginning their work because students' and families' reactions to dissection are often complex. This study explored medical students' experiences of attending an orientation to human dissection and the anatomy laboratory. Students' reactions, feelings, and thoughts were enquired about 1 year after beginning dissection at the University of Auckland, New Zealand. Qualitative research methods, specifically one-on-one semistructured interview were utilized. Third-year medical students self-selected into the study and were interviewed 1 year after entering the laboratory. Transcribed audiotapes of the interviews were analyzed for themes across the interviews. One year after dissection students have vivid memories with differing ways of viewing the body that may help or hinder with dissection. The themes presented include orientation, student anticipation, psychological approach to the body, normalizing-continuing disquiet, and social reference. The orientation eases student entry into the laboratory. There can be ongoing feelings of ambivalence regards the body for some students. Novel findings include that students not only have their own feelings to deal with but also those of friends and family who question them and may feel uncomfortable with the idea of them dissecting. Even one year after beginning dissection, students may emotionally struggle with their work and may require further support, including how they talk about sensitive topics with other people.