History and Ethics of Anatomical Dissection Sabine Hildebrandt

History and Ethics of Anatomical Dissection Sabine Hildebrandt, MD Boston Children’s Hospital/Harvard Medical School Sabine. Hildebrandt@childrens. harvard. edu History & Ethics of Anatomy Hildebrandt

Addressing ethical questions in medicine and anatomy by studying the history of anatomy 1. Why do anatomists need to dissect? Do they? 2. Where do the bodies come from? 3. Do dead bodies deserve respect? 4. How do dissectors save their humanity? History & Ethics of Anatomy Hildebrandt

Anatomy - provides knowledge of the structure and function of the human body - has become “a vehicle for moral and ethical education” in the perception of students of anatomy (Dyer and Thorndike, 2000; Goddard, 2003) Andreas Vesalius (1514 -1564)
De Humani Corporis Fabrica Libri Septem 
(Basileae : ex officina History & Ethics of Anatomy Hildebrandt

Vesalius Juan Valverde Hans von Gersdorf 16 th century anatomists ana-temnein: Greek for ‘to cut apart’, dismemberment History & Ethics of Anatomy Hildebrandt

Ethical issues in anatomy (1) Central ethical problem of anatomy: The paradigm that knowledge has to be gained by dissection, that is: by breaking the taboo of violating the integrity (and privacy) of a person’s dead body. History & Ethics of Anatomy Hildebrandt

this will be my first experience with human dissection. it seems like medicine is full of so many tradeoffs where there is an exchange of some harm for a greater good, […] even in medical techniques like chemotherapy. is dissection similarly an infliction of harm for the sake of the greater good? we will be cutting open bodies, human bodies, that housed people like me, like my mom, like my dad. who lived inside this body? what were they like? what feelings, memories, lessons, experiences were consolidated inside this body? now we will cut it open, not to explore and cherish those contents, but for the sake of anatomical knowledge that will hopefully allow us to eventually take better care of our fellow humans, like my mom, my dad, and the person who was inside this body. . . i hope that tradeoff is worth it. Medical student, Class of 2016 History & Ethics of Anatomy Hildebrandt

Why did we assume to have the right to snip away at the mortal remains of human beings? Did not this man whom I was supposed to ‘dissect’ also have a name before? Who was he? What was his name? Of course, these were only the ‘mortal remains’, not the human being he was before. Did this ‘specimen’ represent nothing other than a piece of chemically treated flesh, an object or thing, with which one may do as one pleases? Hadn’t humans from time immemorial- ultimately into the present- demanded something like piety towards the dead and honored them in cultural rites like for example a burial? Stephan Pfürtner, 1922 -2012, theologian and medical student in Breslau/Wroçlaw 1940 History & Ethics of Anatomy Hildebrandt

Ethical issues in anatomy (2): Where do bodies come from? - as “medical ethics is about things done to the human body” (Barilan, 2005) anatomy needs to answer questions about the ethics of body acquisition for dissections History & Ethics of Anatomy Hildebrandt

Sources of bodies for anatomical dissection in history: -Bodies of the executed -Bodies stolen from graveyards -Bodies of persons murdered and sold for the purpose of dissection -Bodies of suicides -Bodies of duelists -Bodies of “public women” and “unwed mothers” (Germany) -Unclaimed bodies from poorhouses, mental institutions, hospitals, prisons -Donated bodies History & Ethics of Anatomy Hildebrandt

Sources of bodies for anatomical dissection in history 1. period: - bodies of executed criminals - bodies robbed from graves History & Ethics of Anatomy Hildebrandt

First human dissections in Alexandria, around 300 BC Herophilus of Chalcedon, 325 -260 BCE Erasistratus of Chios, 304 -250 BCE History & Ethics of Anatomy Hildebrandt upload. wikimedia. org/ wikipedia/en/thumb/6/66/. . www. health. gov. mt/. . . / issue 1/ipc 0012205. jpgwww. culture. gouv. fr/ ENSBA/Icones/Guillemot. gif http: //archives. cnn. com/2000/books/news/08/09/egypt. library. reut/map. egypt. alexandria. jpg

Galen
(131 -200 CE) Roman physician wrote on all aspects of medicine, including anatomy; no human dissection opioids. com/ opium/galen. jpg History & Ethics of Anatomy Hildebrandt

Mondino de Luzzi (1276 -1326 CE) Public dissections Bologna, Italy medinfo. ufl. edu/other/ histmed/rarey/images/14. jpg History & Ethics of Anatomy Hildebrandt

City of Padua, Italy 1539: bodies of the executed for Andreas Vesalius (1514 -1564 CE) First author of a comprehensive and systematic view of human anatomy, revolutionized the field. http: //www. objectivemedicine. org/images/Vesalius. jpg History & Ethics of Anatomy Hildebrandt

The bodies of the executed were the first legally assigned source of bodies for anatomical dissection Scotland 1506 England 1540 Prague 1600 Padua 1539 Florence 1387 Salerno 1241 Giessen 1676

Anatomical dissection as part of capital punishment William Hogarth: The rewards of Cruelty, 1751 William Smith, murderer, 1750: “As to my corporal frame […] I can not refrain from anxiety, when I think how easily this poor body […] may fall into possession of the surgeons, and perpetuate my disgrace beyond the severity of the law. ” (Hunter, 1931) History & Ethics of Anatomy Hildebrandt www. library. northwestern. edu/. . . /images/1. 70. jpg

Sources of bodies for anatomical dissection in history 2. period: unclaimed bodies, end of 17 th century and after History & Ethics of Anatomy Hildebrandt

1730: Halle, Germany delivery of bodies of the executed and of the poor or imprisoned to the department of anatomy at the University of Halle Department of Anatomy, Halle 1742: Maria Theresia, Austria delivery of the bodies of the executed and the poor to the department of anatomy in Vienna History & Ethics of Anatomy Hildebrandt www. wga. hu/art/ m/meytens/2 maria_t. jpg www. medizin. uni-halle. de/. . . / 561/st_Anatomie. jpg

Grave-robbing became a constant problem in Britain in the late 18 th and early 19 th century due to a lack of legislation concerning unclaimed bodies. Same for the US and its emerging anatomical education in the 19 th century. archive. student. bmj. com/. . . / life/images/04. jpg History & Ethics of Anatomy Hildebrandt

Sources of bodies for anatomical dissection in history 3. period: body donation programs, 2. half of 20 th century - Decreasing number of unclaimed bodies - Medicine becomes effective - Rise of body donation programs, based on state and federal laws: based on the concept of individual human rights, human dignity and voluntary decisions for donation. History & Ethics of Anatomy Hildebrandt

Discriminatory practices in anatomy: the use of bodies provided through questionable legal sources Historical examples: - Use of bodies of the poor, e. g. in 19 th century England (Richardson, 1987) - Use of bodies of “the poor, the black and the marginalized” in 19 th century US anatomy (Halperin, 2007) - Use of bodies of victims of National Socialism in Germany 1933 -1945 Modern examples: - Use of the body of an executed man for the Visible Human Project - Use of bodies of Chinese executed persons for anatomical exhibits History & Ethics of Anatomy Hildebrandt

Results from an archeological excavation of the dissection rooms at the Georgia Medical College: Skeletal remains from dissections 1840 -1880: 79% from African Americans, who made up 42% of the general population 21% from Euro-Americans, who made of 58% of the general population (Blakely and Harrington, 1997) “In Baltimore the bodies of coloured people exclusively are taken for dissection, because the whites do not like it, and the coloured people cannot resist” Harriet Martineau 1838 English travel writer, quoted after Halperin, 2007 History & Ethics of Anatomy Hildebrandt

Medical College of Virginia: Janitor Chris Baker transported the body of executed prisoner Solomon Marable, packed in a barrel of salt. Citizens tried to reclaim the body. History & Ethics of Anatomy Hildebrandt

German Anatomy during National Socialism, 1933 -1945 1. Use of bodies of victims of National Socialism for anatomical purposes: teaching and research 2. Ethical transgression of basic paradigm in anatomy: work with the dead, to new paradigm: work with the “future dead”, i. e. medical experimentation “Justifizierter” [“executed man”], Metzenbauer, 1942 History & Ethics of Anatomy Hildebrandt

Changes in traditional sources for bodies in anatomy in NS period Traditional source New: NS victims Deceased psychiatric patients - include “Euthanasia” patients Suicides - increasingly Jewish citizens Deceased prisoners - new NS laws + increased violence - Ge. Stapo prisoners - concentration camp inmates - forced laborer camp inmates - prisoners of war Executed persons - high numbers due to NS laws - women (incl. pregnant women) Deceased hospital patients Estimated 35, 000 total body supply, percentage of victims unclear History & Ethics of Anatomy Hildebrandt

“[…] I was the only living soul in this hall. The yellow emaciated bodies, bodies of deceased prisoners and executed persons lay there […]. The face looked without expression to the ice-covered attic window, the closed mouth was like a narrow, blue streak. No pain was in his features. I stared at the eyes. They were empty, asked no questions, gave no answers. One body looked like another. Still, they all had once been living human beings, like Frederick, like Björn, like- me. They had waited, despaired, and still with hope in their hearts, this spark of hope that stays with us until the last breath” Hiltgunt Zassenhausen, medical student Hamburg/Germany Memories of the dissection labs, ca. 1942 History & Ethics of Anatomy Hildebrandt

National Library of Medicine’s Visible Human Project (male) The visible human data set: an image resource for anatomical visualization: -CT/MRI, cryosections History & Ethics of Anatomy Hildebrandt

“What we were searching for was someone 21 - to 60 -years of age who died without traumatic injuries or invasive or infectious disease. We got lucky. Some inmates on death row in Texas had decided to donate their bodies to science. They were young, relatively healthy men whose organs, tainted by lethal injection, were rendered unsuitable for transplant. Through screening of cadavers such as these as well as individuals from other donations, our panel selected the body of a recently executed 38 -year-old male. It was not lost on us that victims of executions, a population that taught anatomist’s [sic] centuries ago, would be teaching us once again, perhaps in some way repaying society for their crimes. ” Spitzer and Whitlock, 1998 History & Ethics of Anatomy Hildebrandt

Joseph Paul Jernigan, executed for murder on August 5, 1993, in Texas “legal” use, hence “ethical” “excellent material for the construction of the visible human” History & Ethics of Anatomy Hildebrandt

Gunther von Hagens History & Ethics of Anatomy Hildebrandt

Audit 2003: -1 documented Chinese donor -647 adult bodies -3909 body parts -182 fetuses, embryos, neonates -7 bodies with bullet wounds to the head Von Hagens: - exhibits contain donated bodies exclusively - use of unclaimed bodies for other purposes - body acquisition in strict accordance with the law and “traditions of a given country” History & Ethics of Anatomy Hildebrandt

Whole-body plastinates of unclaimed Chinese bodies, available for a fee from Sui Hongjin, former von Hagen’s co-worker “they are all found by the police and […] nobody claimed them before they were donated to the Medical School” Arnie Geller, President of Premier Exhibitions History & Ethics of Anatomy Hildebrandt

In May 2008, a settlement with the attorney general of New York obliged Premier Exhibitions to offer refunds to visitors when it could not prove consent for the use of the bodies in its exhibitions. New York Attorney General Andrew Cuomo commented: "Despite repeated denials, we now know that Premier itself cannot demonstrate the circumstances that led to the death of the individuals. Nor is Premier able to establish that these people consented to their remains being used in this manner. " History & Ethics of Anatomy Hildebrandt

Ethical issues in anatomy (3): Do dead bodies deserve respect? Ambivalence of the dead human body vs. living body Does the dead body have dignity? Sperling’s “human subject “ and its “symbolic existence” History & Ethics of Anatomy Hildebrandt

Winkelmann (anatomist, Berlin, 2003): Death as part of a persons biography Anatomy as an archeology of the living “Anatomical dissection can be seen as the search for traces of the living in the material world [of the body]” Jones and Whitaker (anatomists New Zealand, 2009): “[…] since the dead body was once a living human body, there is a strand between the two, with mutual connections leading in both directions. ” History & Ethics of Anatomy Hildebrandt

In this sense, donors become our teachers. And while we dissect and find the traces of the living, we also find traces of diseases. Wilhelm Busch, 19 th century Throughout the course, donors will also become our patients. Samuel Luke Fildes, 1891: “The doctor” History & Ethics of Anatomy Hildebrandt

[…] It's amazing to think that--as prospective physicians --we may learn more about medicine from one person in death than any living person we may interact with later in our lives. It's a very special gift from someone we will never know. And yet, we may come to know them in ways that no living person ever had before. I'm very excited to begin dissection. Medical student, Class of 2016 History & Ethics of Anatomy Hildebrandt

Ethical issues in anatomy (4): How do dissectors save their humanity? - development of a balance between empathy and clinical detachment History & Ethics of Anatomy Hildebrandt

Clinical detachment: “The study of anatomy by dissection requires in its practitioners the effective suspension or suppression of many normal physical and emotional responses to the willful mutilation of the body of another human being. ” (Richardson, 1987) “Anatomy is the basis of surgery, it informs the head, guides the hand familiarizes the heart to a kind of necessary inhumanity. ” (William Hunter, 1718 -1783) History & Ethics of Anatomy Hildebrandt www. join 2 day. com/ abc/R/ramsay 6. JPG

On the potential effects of anatomical dissection on dissectors: Anatomical dissection produces a “difference between us and other men in the feelings with which we regard the remains of the dead”. This may give rise to “indifference and even a levity of speech and manner, which are abhorrent to the sensibilities of the rest of mankind” and may happen gradually and unawares. If made aware of this it should “teach us to resist whatever may tend, in any degree, to diminish the tenderness, the delicacy, the purity of mind, which are so peculiarly required in the performance of our duties”. John Ware, Dean of the Massachusetts Medical College Introductory Lecture for Medical Students, 1851 History & Ethics of Anatomy Hildebrandt

- worry about becoming too desensitized (lose the human aspect of medicine by being trained to be tough) Medical student, Class of 2016 History & Ethics of Anatomy Hildebrandt

I could not answer these questions [of the identity of the body to be dissected] for myself, and certainly not at that moment. I simply connected with the attitude I had learned during my medical service during the Poland campaign. It had occurred to me that one could not work as a physician, if one could not abstract oneself from one’s own emotions during certain situations of suffering and emergency, in order to be able to attend with a level head to that which was factually necessary. Stephan Pfürtner History & Ethics of Anatomy Hildebrandt

Balance between empathy and clinical detachment to be a neutral observer and compassionate helper at the same time History & Ethics of Anatomy Hildebrandt

“Yet I also believe that the lesson of anatomy is that we do not need to overcome all our emotion or conquer all difficulty in order to be good clinicians. In fact, in light of the important balance that clinical detachment requires, I should perhaps feel encouraged by my inability to always emotionally disengage. ” (Christine Montross, 2007) History & Ethics of Anatomy Hildebrandt

References: Barilan YM. 2005. The story of the body and the story of the person: Towards an ethics of representing human bodies and bodyparts. Med Health Care Philos 8: 193– 205. Blakely R, Harrington JM. (eds. ) 1997. Bones in the Basement: Postmortem Racism in Nineteenth-Century Medical Training. Washington and London: Smithsonian Institution Press. Dyer GSM, Thorndike MEL. 2000. Quidne mortui vivos docent? The evolving purpose of human dissection in medical education. Acad Med 75: 969 -979 Goddard S. 2003. A history of gross anatomy- lessons for the future. Univ of Toronto Med J 80: 145 -147 Halperin, E. C. (2007). The poor, the Black, and the marginalized as the source of cadavers in the United States anatomical education. Clinical Anatomy 20, 489– 495. Hildebrandt S. 2008. Capital Punishment and Anatomy: History and Ethics of an Ongoing Association. Clin Anat 21: 5 -14 Hunter RH. 1931. A Short History of Anatomy. London: John Bale, Sons and Danielsson Ltd. Jones, GD; Whitaker, MI. 2009. Speaking for the dead. The human body in biology and medicine. Second edition. Farnham: Ashgate Park K. 2006. Secrets of Women: Gender, Generation, and the Origins of Human Dissection. New York: Zone Books. p 15. Richardson R. 1987. Death, dissection and the destitute. Second edition with a new afterword (2000). Chicago; London: The University of Chicago Press, pp 1 -453 Sappol, M. (2002). A Traffic of Dead Bodies. Anatomy and Embodied Social Identity in Nineteenth–Century America. 1 st Ed. Princeton, NJ: Princeton University Press. Sperling, Daniel. 2008. Posthumous interests. Legal and ethical perspectives. Cambridge: Cambrige University Press Spitzer VM, Scherzinger AL. 2006. Virtual anatomy: An anatomist’s playground. Clin Anat 19: 192– 203. Spitzer VM, Whitlock DG. 1998. The Visible Human Dataset: The anatomical platform for human simulation. Anat Rec 253: 49– 57. Warner, J. H. (2009). Witnessing dissection: Photography, medicine and American culture. In: Warner, J. H. , Edmonson, J. M. (Eds). Dissection: Photographs of a Rite of Passage in American Medicine 1880– 1930 (pp 7– 29). New York, NY: Blast Books. Winkelmann, Andreas. 2003. Der endgültige abschied vom Leib? Mit ihrer “Faszination des Echten” Definiert die Ausstellung “Körperwelten” auch, was echat ist und was nicht. In: Bogusch, Gottfried; Graf, History & Ethics of Anatomy Hildebrandt Renate; Schnalke, Thomas (eds. ). Auf Leben und Tod. Beiträge zur Diskussion um di Ausstellung “Köperwelten”. Darmstadt: Steinkopf, p 43 -53