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Current Topics
Building on a Tradition of Ethical
Consideration of the Dead
Medical culture espoiises patient interaction based on detached
concem, where emotional attachment to patients is attenuated to
preserve objectivity. The body is viewed as nonliving matter in mo-
tion. Altematively, the cadaver may be considered a gift. To receive
so awesome a gift is an extraordinary privilege; acknowledgment of
this gift affinns our interconnectedness with our co~unity and of-
fers a way to provide for its betterment. Gift exchange establishes a
relationship between donor and recipient, and the absence of an
assigned worth leaves open the cycle of giving and receiving for future
exchanges. Inherent within undertaking a dissection lies an obligation
that the gift not be wasted. Donating one's body for dissection meetsthe criteria for the highest levels of charity as set forth by the 12th-
During my first year of medical school, I spent
many hours in the anatomy laboratory thinking not
only about anatomy but also about the act of dissection
itself. Retraining myself to invade what was previously
sacrosanct, being required to engage in what was so
recently taboo, was frankly, bewildering. How was I to
forget that this cadaver was once a living being long
enough to dismember and explore deep into her tis-
sues? Leon Kass,a physician and ethicist, in discussions .
with first-year medical students immediately after their
first experience in the gross anatomy laboratory, writesthat "almost everyone who spoke acknowledged the
need and desire to respect the mortal remains. . . but
those who were most troubled somehow intuited the
impossibility of doing so. They understood and felt that
they were engaged in something fundamentally disre-
spectful-albeit for a good cause."]
In an attempt to bring into sharper focus the sa-
cred dimension of our task, I composed a brief per-
sonal, Hebrew prayer to recite at the start of each labo-
ratory: Baruch ata adoshem, elokeynu melech haolam, asher
kideysh avodat yadeynu l'avodat'cha hak'dosha[Blessed are
You, Sovereign of the universe, who has consecrated
the work of our hands to Your holy service]. This was
followed by the creation of an Interfaith Service for
Thanks and Respect, which was held one week before
the first gross anatomy laboratory. The relevance of this
preparatory interfaith service is underscored by the fact
that it was attended by nearly one third of my medical
school class, faculty members, nursing students, and
hospital chaplains. The prayer and service were helpful
From the Case Western Reserve University School of Medicine,
Cleveland, OR. Accepted for publication January 25, 1995.
Address correspondence and reprint requests to Roxanne B.
Sukol, MD,3882 Bethany Rd, University Heights, OH 44118.
Copyright 1995 by W.E. Saunders Company
0046-8177/95/2607-0001$5.00/0
century philosopher, physician, and rabbinic scholar Moses Maimon-
ides. Preserving the anonymity of cadavers protects students as well
by enabling them to dissect in an environment that respects the sensi-
tive and difficult nature of the work. Maimonides provides support
for formalizing the anonymous relationship between student and ca-
daver. The anonymous nature of the gift provides enormous latitude
for using the skills thus gained to serve one's patients and to benefit
the common good. HUMPATHOL26:700-705. Copyright 1995 by
W.B. Saunders Company
Key words: cadaver dissection, ethics, Maimonides, medical stu-
dent socialization.
to me but only partially. The fact of my cadaver's for-
merly l~vingstatus continued to trouble me. Initial be-
wilderment was eventually assuaged somewhat by a
sense of the profundity of her gift, the recognition of
which was soon followed by thoughts on the implica-
tions of accepting such a gift.
At the medical school I attend, we are informed
that every body is donated with the consent of its for-
merly living inhabitant. The comments contained in
this article are based on this reality. To dissect a body
and know that consent was never given is a radically
different, and probably more difficult, matter. Freder-
ick Hafferty, whose findings are discussed in more detail
later, writes that all the students he interviewed were
convinced that they had a donated body, although they-
all knew that a significan t percen tage of the bodies used
for dissection at their medical school had not been
donated. Despite the extreme unlikelihood of all the
students having received donated bodies, they were all
nevertheless convinced that theirs was definitely one of
the donated ones.2 Reminding oneself that one's ca-
daver actually chose this fate is one of the ways that
students reassure and protect themselves as they pro-
ceed to dissect.
There is general agreement in the published litera-
ture that the means by which medical students come
to terms with their'cadavers has broad significance for
later interactions with their patients.3-8An article pub-
lished in The Nation provided examples from the au-
thor's own medical training to support her belief that
depersonalizing the cadaver prepares medical students
for later depersonalization of patients. It is an intriguing
concept. How many parallels can be drawn between a
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cadaverand a patient? As student doctors, we conduct
our first procedures on cadavers, dissect out anatomic
structures, use language similar to that heard in the
operating room, wear scrubs, and so on. Inasmuch as
medical culture espouses patient interaction based on
a model of detached concern, where emotional attach-
ment to patients must be attenuated at the risk of com-
promisingone's objectivity,9 medical students begin im-
mediately to adopt this model in the gross anatomy
laboratory.
In his ground-breaking study Into the Valley: Death
and the Socialization of Medical Students, Frederick Haf-
fertyobserved and participated with first-year students
at an urban medical school throughout the course of
theiryear-long experience in the anatomy laboratory.
In extensive interviews, Hafferty heard students de-
scribethe dissection experience as a good opportunity
forlearning to detach themselves, with the recognition
that this skill would also prove useful later in the hospi-
tal. In actuality, the students' ability to detach them-
selveswaxedand waned through the year based primar-
ily on the body part being dissected, with the most
difficultbeing the head and neck, hands, and genitalia.
Issuesof mortality play an important part in objecti-
fyingthe cadaver. Hafferty devotes an entire chapter to
the "ambiguous man," so called because of what he
refers to as the cadaver's ambiguous state as partially
human yetpartially not. Labeling the cadaver clearly as
"not-me" obfuscates identification with the cadaver
and thus consideration of one's own mortality. Yet the
cadavercannot help but display its humanity to all who
encounter it, and students are not always successful at
maintaining their distance.According to Hafferty, only a few students consis-
tentlyperceived their cadavers as biological specimens,
without regard for their formerly living status. Several
students whom he interviewed expressed uneasiness
withthe fact of other students' successful detachment,
despite concurrent and extensive attempts to emulate
them. Thus, it appears that although there was
agreement about the importance of maintaining one's
objectivity,these first-year students were still not con-
vincedthat it should be gained at the expense of com-
plete detachment.
Kassobserves that although nonmedical personnelare expected to experience a strong aversion to the
cadaver, this reaction is considered inappropriate and
unreasonable for medical students, for whom the cor-
rectposture must be one based on a scientific perspec-
tivethat regards the living body as nonliving matter in
motion. Although at some previous time it would have
been perfectly reasonable to feel queasy in an anatomy
laboratory, one is expected to undergo a transforma-
tion on entering medical school. Fox9 extends the de-
velopmentof detached concern to include the impacts
ofattending one's first autopsy as a second-year medical
student and performing procedures on live animals.
Physicians-in-training become part of a adaptation pro-
cessthrough which they learn in a stepwise fashion to
suppress emotional responses, and dissociate them-
selves more and more efficiently from emotionally sig-
nificant aspects of their work.
As part of the interviews, Hafferty' asked students
if they would consider donating their own bodies for
dissection. Of the 99 total students, 82 said no, 11 said
yes, and 6 were undecided. He reports that all aban-
doned the customary calm they had maintained
through their interviews, and responses became abrupt,
tension laden, and filled with emotion. Of those who
said yes, the primary reason given was their perceived
academic importance of dissection. Nine of these 11
had high attendance records in anatomy laboratory,
and 10 had a primary definition of the cadaver as a
formerly living human being. They considered this per-
spective an important means of fighting against the de-
tachment inherent in the laboratory experience. Haf-
ferty concludes that good adjustment to the laboratory
is a three-part process that requires recognition of the
cadaver as a generalized other, acceptance of it as a
personal symbol, and successful adaptation to the ten-
sion endemic to these perspectives.Thoughts about the cadaver-as-self obviously in-
volved recognition of the self as mortal. The anatomy
laboratory is where medical students begin to construct
an image of the physician as fundamentally different
from laypersons. Medical students learn to expect and
count on differences in knowledge and experience be-
tween physicians and laypersons. As mentioned earlier,
it was important for students to imagine that their ca-
daver was donated. But did these donors truly give a
fully informed consent? Hafferty suggests that the re-
fusal to entertain the prospect of donating one's own
body may imply a belief that the formerly living person
did not fully understand what would happen and, there-
fore, did not really give informed consent. VancelO
notes that the reluctance of physicians to consent to
autopsies of themselves or their family members illus-
trates an inherent conflict between two rationally held
values: the goal of the medical profession to be self-
critical as weighed against cultural beliefs regarding ap-
propriate treatment of the dead.
Hafferty found that instructors' teaching styles had
a serious impact on student attendance in gross anat-
omy. He showed that students assigned to groups whose
instructor acknowledged the emotional significance of
dissection continued to attend laboratory in unusuallyhigh numbers for the duration of the course. This ac-
knowledgment was generally brief and consisted simply
of the fact that it was all right to feel uncomfortable
under the circumstances. In contrast, students assigned
to groups whose instructor was particularly insensitive
(eg, leaning on a cadaver's face at orientation, charac-
terizing students who expressed discomfort as weak or
even unsuitable), were much more likely to begin miss-
ing sessions and then to cease attending altogether.
Students assigned to instructors who were neither sensi-
tive nor particularly insensitive, but who nevertheless
did not acknowledge the potentially distressing nature
of dissection also had an attrition rate much higher
than that of students whose instructors acknowledged
the legitimacy of any distress they might feel. One stu-
7/28/2019 tica en autopsias (Sukol)
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dent stated that although laboratory orientation might
have provided a valuable opportunity for faculty mem-
bers to emphasize physicians as sensitive and caring, it
was instead an alienating event. The dramatic differ-
ences illustrated by these surprising findings should be
of interest to all medical educators.
What makes it so difficult to dissect a dead human
being? What is it about dissection that seems like such
a violation? To the lay person, the answers seem so
obvious as to make such questions absurd. To the medi-
cal community, however, any obvious answers to these
questions have been long forgotten. If for this reason
alone, asking ourselves these questions once again is
worthwhile.
Kass1provides some insight in his discussions con-
cerning the sense of responsibility that human beings
feel toward their deceased, those to whom they are con-
nected by ties of kinship. He explains that an individu-al's perception of one's place in the line ofgenerations
is crucial to the development and preservation of soci-
ety and culture, to the fabric of that individual's world.
To disrupt this chain is to disrupt a person's grounding
in the world, the internal systems by which one orga-
nizes one's thoughts, perceives right and wrong, and
perhaps maintains one's sanity.
All cultures have sacred ceremonies and customs
concerning the treatment of their dead, with burial and
cremation being those most familiar in Western society.
Following the death of a loved one, the rituals of our
community often become of heightened importance,
and we perform them faithfully. We work to ensure thatthe body of the recently deceased is adequately cared
for, and not treated inappropriately. The purpose of
these practices, particularly the last, is not simply to
facilitate entry into the cycle of grief and healing but,
as Kass1notes, to maintain one's place in the very cycle
of humanity. Words from the Order of Christian Funerals
express this so clearly, "Though separated from the
living, the dead are still at one with the community of
believers on earth.. . . The community. . . recognizes
the spiritual bond that still exists between the living andthe dead." 11
Another example concerns the transplantation of
organs from cadaver donor sources. In contrast to other
parts of the world, this practice has not been used widely
in Japan. Feldman 12 asserts that the reasons stem in
part from Shinto-based beliefs that the welfare of the
living is dependent on paying appropriate homage to
the dead. The human body and its meaning hold uni-
versal truths for those to whom it is entrusted.
Abraham Joshua Heschel, aJewish ethicist, philoso-
pher, and theologian, explains that the universal truths
of the human body transcend the truths of those to
whom the body is entrusted. Heschel13 invokes the bibli-
cal story of creation in his reflections on the holiness
of humanity. According to Genesis, human beings were
created in the image of God, and "the image is not in
human beings, it is human beings." The sparing use of
the image of God throughout the Hebrew Bible "re-
minds us that the body of man, not only his soul, is
endowed with divine dignity."13
Heschel emphasizes the partnership between Godand human beings. He describes the vital needs of the
body and soul as being of divine concern, and explains
this as evidence that human life is indeed holy. He
writes that although the divine likeness of the human
form is an idea familiar to many religions, 'Judaism
contributed the tremerrdous implication of that idea:
the metaphysical dignity of man, the divine pre-
ciousness of human life. Man is not valued in physical
terms; his value is infinite."13 Despite the fact that com-
mon sense would tell us two human beings are more
than one, Heschel reminds us that Jewish tradition
teaches that to cause one single soul to perish is as if
one had caused the destruction of the entire world; tosave one single soul is as though one had saved the
entire world. Each individual human being is precious
and sanctified.
Heschel is concerned with the routine activities of
everyday life. Although they may seem ordinary, each
of them possesses intrinsic sacred value as an event in
the unfolding, or creation, of the universe. We are
granted the ability to acknowledge the sacredness of
such activities by identifying them in time, thereby sanc-
tifYing the concept of time as well. What separates a
common activity, such as eating, from its sacred dimen-
sion is the simple act of acknowledgment. To Heschel,
reciting a blessing when one eats, awakens, washes one'shands, or even dissects acknowledges the sacred dimen-
sion of that activity and elevates it to its valid place in
creation.
Reciting a blessing before the beginning of each
dissection laboratory has given me a way to acknowl-
edge not only that my cadaver contains mysteries I will
never understand but that we are both part ofthe same
universe.
Martin Buber14describes twopossible kinds ofreIa-
tionships in the world: I-Thou and I-It. One enters into
an I-Thou relationship with one's entire self. "I" is not
distinct from "Thou," and the resultant I and Thou
form a single entity that is defined as I-Thou. Con-
versely, where "I" becomes distinct unto itself, the rela-
tionship is termed I-It, an association between two sepa-
rate entities. The subject of the I-Thou relationship is
the relationship itself; no object exists within the rela-
tionship. The subject ofthe I-It relationship is "I," who
perceives "It" as the object.
The cadaver as biological specimen is an object
whose purpose is defined entirely by the medical
school's perception of its purpose. The medical student
becomes "I" and the cadaver "It." This perspective is
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not entirely disadvantageous, because the student who
is unable to separate sufficiently from identification
withthe cadaver will be unable to dissect at all. I-Thou
identification with family members and friends may be
whatmakes contemplation of their dissection, even by
others, so gruesome.
The goal is not to aspire to achieve an I-Thou rela-
, tionshipwith one's cadaver. Rather, it is to appreciatethat the cadaver itself was once a human being who,
independently, had the capacity to participate in his or
her own I-Thou relationships. The person who inhab-
ited this body assuredly had significant relationships
with others; memories of this person and his or her
- influences, for better or worse, are now carried by the
'people who survived and for whom his or her memory
ismeaningful.
Cadaver as Gift
Thomas Murray,15 discussing blood donation in
the United States, declares that gifts of the body areaffirmations of the need to define our community and
ourinterconnectedness with its members. Giving some-
thing of oneself, here an actual part of one's body,
defines the greater community of which one is a part,
confirmsits importance, and offers the donor a way to
provide for its betterment.
Last year, the New York Times Magazine featured a
story about a man trying to fulfill his father's dying
wishto donate his body to science.16 An appalled and
bereavedson was directed to begin his inquiry into the
logisticsof such a task with the attending physician.
The physician, once he understood the basis for the
man'srequest, reassured him that his actions were' 'very
honorable ... no ... very noble" and that his father
was making "a truly generous gift." The physician's
wordsled the man to consider that there might be at
least a couple of "true healers" among the roomful
of "wisecracking medical students ... making snide
witticisms" who would one day dissect his father'sbody.16
Donating one's body for dissection meets the crite-
ria for the highest levels of charity as set forth and
ranked by Moses Maimonides.17 Maimonides, a 12th-
century Spanish physician, philosopher, and rabbinic
scholar,believed that aiding a person to become self-supporting (ie, to earn a living) was the highest level
ofcharity. He further stated that charity from one indi-
vidualto another, the identity of each unknown to the
other, was the second highest level of charity. Further
down on the list was the case where the donor and
recipient each knew the identity of the other, and fur-
thest down was the case where the donor gave grudg-
ingly.
Donating one's body for dissection provides its re-
cipient(s) with not only the opportunity to learn a par-
ticular body of knowledge and set of skills, but also, it
turns out, the ability to earn .a livelihood. Thus, the
donated body becomes a means by which an anony-
mous donor assists another individual to become self-
supporting. Maimonides considered this to be the high-
est level of charity.
Donors of bodies and their medical student recipi-
ents are unknown to one another, and arrangements
for transfer of bodies to medical schools usually are
made by the schools themselves. At the medical school
I attend, and at all others as far as I know, one never
knows the identity of one's cadaver. To prevent such
an eventuality, we are requested specifically to notify
the faculty if we know of anyone who has donated abody within the past 2 years. Of course, donors will
never know the identity of those who receive their bod-
ies, not least because, in many cases, the students have
not yet even been accepted to the school. The doubly
anonymous nature of these donations meets the criteria
for Maimonides's second highest level of charity.
Concern about having to dissect someone you
know is nothing new. Among the various kinds of maca-
bre jokes traditionally told by medical students, Haf-
ferty18 includes the category of "cadaver as r elative/
friend." In the past, these jokes have always served as
a socially sanctioned (ie, by medical school culture)means for expression of the various kinds of anxiety
engendered by dissection. Preserving the anonymity of
cadavers protects students as well by enabling them to
dissect in an environment that respects the already sen-
sitive and difficult nature of this work. Maimonides pro-
vides support for formalizing the anonymous relation-
ship between the student and an autopsy or an
anatomic dissection.
The cadaver is a profound gift made b y its donor
(ie, the formerly living person) to students of medicine.
Lewis Hydel9 distinguishes between gifts and commodi-
ties in The Gift: Imagination and t he Erotic Life of Property.
A gift has intrinsic value; a commodity has monetary
worth. Commodities are bought and sold in the market-
place as part of an interaction with limited boundaries,
whereas gifts are not limited in the same sense. Medical
schools do not purchase ca.davers, nor are organs sold
to hospitals. In recent years, hastened by an understand-
ing of how the purchase of blood products was contrib-
uting to the spread of the acquired immunodeficiency
syndrome (AIDS) and hepatitis, we have seen blood
banking converted almost entirely to a voluntary sys-tem.15,20
The exchange of a gift establishes a relationship
between its d onor and recipient, and the absence of
an assigned worth benefits those who participate in its
exchange by leaving open the cycle of giving and receiv-
ing for future exchanges. Discussing the system of gift
exchange engaged in by the Trobriand Islanders of Me1-
anesia, Marcel Mauss explains that the act of receiving
commits oneself to the partnershw, and failure to re-
turn gifts means a loss of dignity. For a modern-day
example, if you need to prune a tree in your yard,
you can borrow a saw from your neighbor, or you can
purchase one at a hardware store. The first kind of
interaction, borrowing the neighbor's saw, engenders
a relationship with certain associated obligations,
~hereas purchasing one does not.
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Obligations of the Recipient
Murray writes that paradox is characteristic ofgifts:
"Their motivation often seems both selfish and un-
selfish. They are given under conditions of freedom,
yet are powerfully binding. They must be given gener-
ously and without promise of return, yet they must be
reciprocated."22 There is responsibility inherent in ac-
cepting a gift; the act of receiving commits one to the
relationship.
- Along with the gift comes responsibility, and what
one does, and intends to do, with one's cadaver and the
knowledge gained from it, constitute the basis for that
responsibility. The issue of purpose, therefore, is an inte-
gral element of the obligation. In an immediate sense,
the individual who accepts a cadaver for dissection makes
a personal commitment to take advantage of that gift,
to use the opportunity to learn as much as possible about
the human body. To accept a cadaver in the spirit in
which it is given, it is imperative that the gift not be
wasted. As Vance23explains, performing autopsy (or dis-
section) in the pursuit of knowledge is a direct extension
of the physician's commitment to be competent. Theobscenity would be to waste the opportunity to make the
dead have meaning for the living.
The obligations of the individual who undertakes
performing a human dissection are threefold: to one-
self (ie, the dissector), to one's cadaver (ie, the donor),
and to one's community. The first obligation is to one-
selfand concerns acknowledgment. To receive such an
awesome gift is indeed an extraordinary privilege. This
simple truth is the essence of the obligation.
One's second obligation, to the cadaver/donor,
concerns the issue of respect. Acknowledging the awe-
some nature of this individual's gift, as described pre-
viously, necessarily directs one toward respect. Clearlywe can never know a donor's particular motivation for
having made a gift. Vetwe can express our appreciation
and gratitude for this final behest in literally an infinite
number of ways-in silence or aloud, in solitude or
company, in word or deed.
One's third obligation, to the community, is re-
lated to the connection made by Murrayl5 between gifts
of the body and affirmation of the community. Having
received an education and livelihood in part from the
cadaver, one may then consider how best to use the
skills thus gained to serve one's patients, to benefit the
common good, and to reciprocate this gift from the
community. Fortunately, as infinite as the means forexpressing appreciation to the cadaver, so too are those
for expressing appreciation to the community. Th~
anonymous nature of the gift provides enormous latI-
tude for doing so, and our careers as professionals and
community members will offer numerous and varied
opportunities to return the favor.
Standing in anatomy laboratory, I cannot help but
be moved by the human body that lies before me. Sev-
eral of my classmates have told me that they stop dis-
secting relatively frequently to remind themselves that
their cadavers willingly donated their bodies. Dissecting
is a difficult task. At the end of the school year, many
medical schools hold a memorial service for cadavers'
family members and medical students to commemorate
the final disposition of the remains of the dissected
bodies. A member of the class ahead of mine told me
how surprised she was initially to see family memberscrying at last year's memorial service because she had
almost forgotten there was anything to cry about. They
are a powerful reminder that we dissect not some model
biological specimens, but mothers, fathers, sister~,
brothers, friends, teachers, caretakers, lovers, mUSI-
cians, scientists, comedians, and philosophers.
The cadaver has much to teach us, and those who
shield themselves from its humanity also shield them-
selves from some of the most important lessons of all.
The obligation may at times seem obscure, but acknowl-
edging the gift and all that it entails has broad implica-
tions for medical education and practice. The profun-
dity of the gift merits such thoughtful consideration.
Acknowledgment. I would like to acknowledge the guid-
ance of Dr Stephen Post at the Center for Biomedical Ethics
at Case Western Reserve University.
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