Perspectives on anatomical donation and holding services of thanksgiving

Introduction

When discussing the subject of donation and ‘need’ for remembrance and thanksgiving, it is useful to reflect on the historical events that have led to many of the body bequest programmes in place today. Human dissection has been the cornerstone of anatomical learning since the time of the ‘great’ 16th-century anatomists such as Andreas Vesalius. At that time, the bodies used for dissection were not those donated voluntarily ‘for medical science’ as today, but usually those of executed criminals. As anatomical and medical training expanded, the number of bodies made available for dissection could not meet the demand. In Britain, for instance, shortages in the 19th century led to increases in body snatching to provide anatomy schools with bodies ‘on demand’ and in some cases people were even murdered for the value of their body, one of the most famous cases being the ‘Burke and Hare murders' in Edinburgh. ¹

Such crimes led to the establishment of the Anatomy Act of 1832, which sought to eradicate body snatching, as bodies of all unclaimed poor could legally be used for dissection. Today, the Human Tissue Act (2004) governs the use of human tissue in the UK (except for Scotland). Enshrined at the heart of the Act is the fundamental principle of consent, so that individuals must decide in life if they wish to donate their body to medical science after their death. Similar bequest programmes are in place around the world and are most often focused on the wishes of the donor.

The value and challenges of the human body in dissection

In medical courses, the challenge for anatomy teachers has been to present the intricacies of the human body in ways that provide information about the function of a particular structure, and also ways of remembering it. There has been an ongoing debate over the last decade about the best way of instructing students in anatomy and what approaches to use. ^2–5 However, despite changes in curricula and the rise of new technologies, dissection of the human body remains at the heart of anatomical teaching for many medical schools in the UK and around the world, with the belief that it is still the best way of introducing anatomy to medical students and those in the related health professions. Dissection certainly provides an opportunity for students to uncover, see and feel for themselves the main structures of the human body in three dimensions, to appreciate the natural variation between bodies and to start to understand what happens when tissues and organs have become diseased or damaged during life. ^2,4,6,7

While dissection provides a scientific and intellectual basis for their studies, it also exposes students to questions and reflections on human mortality. For many students this will be the first time that they have been confronted by death. ^4,8–10 The introduction of death and dying so early in a medical student's career can be particularly challenging to students who believe they have entered a profession which prides itself on saving and improving lives ¹¹ and for some, their responses might, at least initially, culminate in a negative experience of dissection. Students need to receive appropriate preparation and support prior to, and during, dissection sessions. ^10,12–15 Students are therefore often given introductory lectures that explore the donation process and what will be expected during dissection. They are provided with opportunities to explore feelings and discuss topics stimulated by their involvement in dissection and encouraged to reflect formally on their thoughts and experiences to help develop humanistic qualities. ^9,14,16

Donors as patients

Students have been increasingly encouraged to think of, and treat, their donors as patients. It is argued that such an approach provides a basis for developing and reinforcing attitudes of respect and compassion in students from early in their training and also promotes professionalism. ^16–19 Providing an emphasis on the donor as a patient can, of course, lead to increased curiosity, with students wishing to know about the source of the donors and in particular specific donor information such as names, life histories and cause of death. Disclosure of such information to students has been encouraged in order to help personalize the donor. ¹⁶ However, in England, Wales and Northern Ireland, the body donation and bequest programmes in place at medical schools fall under the regulations set out in the Human Tissue Act (2004), legislation built upon the fundamental principles of donor consent and respect. Therefore, when deciding what information should be provided to students, a careful balance has to be reached so that the wishes and rights of the donor are protected. In most cases this means that donors remain anonymous to the students; however, information such as age at death and recorded cause of death is usually given to students. In many cases, students choose their own names for the donors, which helps create some identity and therefore relationship with the donor. ¹⁶

While referring to donors as patients provides an avenue for personalization, some believe there is a danger that because their patient is silent, students may assume a paternalistic approach in relation to their donor, which would not be encouraged as a positive patient–doctor relationship. ²⁰ In addition, students are unable to ‘help’ their donor in the same way as they would a patient, and while they can identify a number of pathologies as they dissect, they are unable to carry out treatment or improve health.

It is clear that there needs to be a careful balance that provides for the humanization of dissection while focusing on learning the intricacies of the human body and allowing students to experience the awe and wonder of discovering a structure or organ for the first time. One way of helping students achieve this might be to introduce the donors as one of the student's first teachers and this phraseology is now common at Brighton and Sussex Medical School (BSMS). In this way, the donor is empowered to be the students' primary tutor and portal for learning, with the staff acting more as facilitators. Such an approach is also in keeping with the desires of many donors who wish to help educate students and doctors. Body donors have been referred to as teachers in a number of countries for many years, with medical schools in Thailand holding dedication ceremonies called waikhru for the donor, which means ‘honour the teacher’ and during which the donors are given the title of ajarn (teacher). ^21,22

Giving thanks

As part of the growing appreciation of the humanistic side of dissection and a desire of students to ‘thank’ their donor at the end of the dissection experience, many medical schools around the world hold a service of thanksgiving or memorial to which relatives and friends of the donors are often invited as well as students and staff. ^4,15,22–24 These services vary greatly in nature from informal events in classrooms and laboratories to more formalized ceremonies in lecture theatres, event halls and places of religious worship. ²³ In some cases students organize and lead the event ^9,25,26 while in others students are encouraged to contribute by reading poems and reflections or by providing musical accompaniment. ^11,15 The titles used for the events also differ: ‘Memorial Service’, ‘Service of Thanksgiving’, ‘Convocation of Thanks’, and ‘Service of Gratitude’. ^{4,11,15,16,23} Despite these differences, all such events afford an opportunity for students to honor and celebrate the gift of the donors, help to reinforce respect and also appear to provide a sense of closure for a process that, for some students, is an emotionally intense period of their early training. ^16,27

There are two annual services of thanksgiving in which BSMS plays a part. The first is a service organized by the London Anatomy Office which is held in central London and includes all the medical schools in London and south-east England. This largely ecumenical event, primarily for the friends and relatives of the donors in this region, is also attended by faculty and religious leaders and is ‘hosted’ by the students and staff of one of the medical schools in rotation. Bringing the various regional schools together generates a much larger event and one, as many relatives have pointed out, that provides a real sense of occasion that honours their loved ones. Relatives have told the organizers of the services over the years how much they appreciate the presence of both the staff and students as they are able to tell stories about their donor relative and hear how the gift of donation has helped in teaching the next generation of doctors and health-care professionals.

The second service is a short, local, event held in the Anatomy Laboratory at BSMS designed as a non-religious occasion for all second-year students to show their gratitude to the donors at the end of their main anatomical training. The anatomy staff and local chaplain lead the service, although students are also encouraged to contribute. Relatives are not invited to this second event.

We chose just the second years as we could accommodate all second-year students within the laboratory and felt that it would help to provide a means for these students to have a sense of closure at the end of their dissecting experience. Choosing to hold the service in the laboratory was deliberate as we wanted students to experience the anatomy laboratory environment without any of the hectic activity of a normal teaching session. We also felt that this would provide a time for students to pause and reflect with their donors present. We display a list of the real names of the donors at the ceremony although we do not relate the names to the individual donors. For many students this appears to be the most emotional aspect of the service, probably as they have not seen the real names before, and one that resonates for some time afterwards.

For some students it is purely an event to give thanks and to respect the donors, while for others it provides an opportunity to reflect and remember the experiences they have had over the first two years of their training and how the donor has been a key part of that. It is an emotional time for some students and therefore striking the right balance in terms of content and format during the service and providing the appropriate source of support at the end has been a challenge.

Exploring the views of medical students

Because thanksgiving services are an integral feature of many medical schools and students often play a central role in them, we decided to explore the views and thoughts of first- and second-year medical students on holding such events. Six volunteer students from each year group (years 1 and 2) all of whom were carrying out human dissection at BSMS were recruited to participate in focus groups exploring student views on donor thanksgiving services. We asked these students about the purpose and value of thanksgiving services, and their expectations of what format might be used and what content should be included. We also questioned how services might relate to, or have an impact on, students' own experiences of dissection.

The focus groups highlighted that medical students share common feelings regarding the value and purpose of donor thanksgiving services. Students were unanimous in their view that services of thanksgiving should be an integral part of the dissection experience at medical school and agreed that such opportunities provide a setting for students to show their gratitude for the gift of donation, to bring closure to anatomical studies and re-humanize the dissection experience. Following attendance at the local service, some of the focus group participants noted that it felt like the student community had come together. Other studies have reported that services of thanksgiving help to strengthen the social bonds between students. ¹⁶ Most students felt that a service was the best and most fitting way to pay respect to the donors and, when asked about alternatives, most ideas were related to adapting or adding to thanksgiving services rather than suggesting an entirely different approach. This feeling appeared to be linked to the suggestion by some of the students that the value placed on dissection is inextricably linked to that placed on a need to say thanks. However, other students concluded that the relationship between dissection and the service of thanksgiving was probably not that simple and suggested that dissection has separate educational and humanistic values and the latter is more connected to the need for a thanksgiving service.

The results of the discussions showed that students had specific ideas about the format and content of a service of thanksgiving and, despite neither group of students having experienced the services, many of their ideas reflected, perhaps unsurprisingly, what actually happens in each service. Many agreed that this was an opportunity to demonstrate their professionalism through their desire to be actively involved in the service and also in discussing what they should wear for such an occasion. Many of the group members expressed a committed view that the service (both local and regional) should be held in a religious building as they felt this provided the appropriate venue and atmosphere. In addition, they commented that having a chaplain or similar individual lead the service is desirable. Interestingly, though, they did not wish to see an overtly religious format to the service and it appears that this is more to do with making sure that this is an inclusive rather than an exclusive event in contrast to thinking about the beliefs of the donors or their families. Anecdotal evidence from relatives attending the regional service in London suggests that they too feel that having at least some religious surroundings or leaders present at the service appears to set the right tone, irrespective of their own beliefs. It might be that the location has a real influence on how the service is perceived and may affect whether some students achieve their desired outcome.

Attendance at the services played a significant part in the student discussions. Both focus groups felt that it was desirable for all the students in a cohort to attend the service, but thought that the event should not be compulsory. They recognized that there may be reasons for some students not wishing to attend, such as the recent loss of relatives; however, collectively they remarked that they would be strongly opposed to students not attending for ‘frivolous’ reasons. The question of whether relatives and friends should be invited to the services produced a distinct difference between the groups, with first years largely opposed to the idea and second years in favour. First-year medical students will have less experience of patients and their relatives in comparison with second-year students and might be more anxious about how they might react in front of them. Therefore, inviting them to a service might be seen as a barrier to some. Alternatively, students earlier in the course might think that the service is a more personal event for them to say thank you rather than being able to share the experience with others outside their peer-group.

Many of the second-year representatives expressed a need for the presence of the relatives and would therefore have a preference for the regional service where relatives are prominent. Attendance at services where friends and relatives are present allows students to meet and interact with them and may provide opportunities to understand more about individual donors, while providing the families with a chance to meet students who have directly benefited from the gift their loved ones have given. ²⁷ It might be that students believe that being able to show their gratitude in person to relatives is one that contributes to their professionalization. But given the different opinions between the year groups, it suggests that when designing thanksgiving services, the decision to invite relatives to attend must be balanced against the wishes and status of the particular student group involved.

While the focus groups only involved a small percentage of the student cohorts, the study provided an insight into some of the views medical students have on the purpose and value of thanksgiving services as they relate to the anatomical donation process. The results of the discussions clearly demonstrate that students have strong opinions about the purpose and format of thanksgiving services and are highly supportive of them being an integral feature of their dissection experience. This view appears to be heightened among students after attending a service.

Conclusion

Dissection of the body continues to play a fundamental role in the life of many medical students. While such an opportunity provides students with a unique educational insight into the structure of the human body, it is clear that such an experience also appears to help in increasing the development of professionalism skills and, for many students, evoke profound thoughts and emotions. The donor sits at the heart of this multifaceted journey for students, acting as a teacher, guide and companion. It is therefore essential that students be aware of the process of body donation and be provided with opportunities to explore their own feelings in relation to the human context of death and the role of their donor, and to demonstrate their thanks. This sits well with the regulatory basis of body donation in most countries where the process is built around the consent of the donor. For students, this helps underpin the importance of the individual's rights early in their medical training. The focus group study at BSMS strongly suggests that for those looking at introducing such thanksgiving services into their anatomy programmes or adapting services already in place, it is essential to include students at the design stage to ensure that their aspirations and outcomes are met.