Friday, March 12, 2010

Oh Father, Where Art Thou?

My Dad donated his body to science 28 months ago. I was notified yesterday that that they
 have finally finished with him, and whatever was left  has been cremated. I am glad it's over. My
 "share" is next to my recliner in a handsome box, which I can embrace whenever I wish.

    March, 2010: The part that hurts and haunts me the most is when they tore back his face. I am crying even as I write about it. What did they do with my father's face?
   He sounded so matter-of-fact when he mentioned several years ago that he would be donating his body to the medical school upon his death. I didn’t pay much attention to it, because it seemed so consistent with his scientific rationality -- he was a chemist -- and his ethical imperative to do the right thing.
    I also paid it little mind because I couldn’t imagine that anything could hurt me more than his death itself. I was wrong.

     Do you intend to donate your body to science? I was surprised to learn that every major religion sanctions, implicitly or explicitly, body donation as a charitable and blessed act in the eyes of God. If you believe what you say you do about life and death, God and good, how do you justify withholding this precious gift from your fellow man? 
    The reality is that only one in every several thousand  people in the U.S. signs up for whole-body donation.
    Why is this? Our other two options are to become "food for worms" as we rot in the ground, or to emerge from the crematorium as a few ounces of ashes. Is there something so fundamentally repugnant or painful about being carved up into our component parts that the vast majority of us simply can't handle it -- even though we're as dead as can be, and wherever we are, it's not there? Can we not endure it even though our "gift" will enlighten a future doctor, or help create technologies that improve the lives of countless human beings?
    What is your problem? I know what mine is: Love, pain, tenderness and horror.

Daddy! Where art thou?

    This companion article investigates the "cadaver industry." Think before you donate.
    My father's body has been at what I refer to as “the abattoir on the hill” since he died, and I am as haunted as ever by images of what is being done to his remains. My brain is flooded with scenes of butchery. That body I came to know so well at the end, when he needed help doing everything, and those hands and cheeks that I kissed so much because that was the best way to communicate with him -- they have been sliced, shredded and trashed. It hurts me deeply.
    We are fortunate that he is at a university, where we can expect at least some degree of care and respect. Many of those who donate their bodies "to science" are used as crash-test dummies (yes, it's still being done, in the 2011 Ford Explorer, for one. They say nothing can quite compare to a real body). The NFL tests helmets on human cadavers, and NASA uses them to gauge the stresses placed on the brain and spine during rapid descents. Donated bodies are strung up for target practice, to test the amount of damage that various bullets can do, and they are placed in all sorts of environments -- swamps, deserts, ponds, caves -- to chronicle the nature and speed of their deterioration, putrefaction and ultimately their explosion, from the buildup of internal gases. Or, they chop off your head and use it to help cosmetic surgeons practice new techniques.

   At the University of Utah, they keep the "cadaver area" under such tight security that you'd think they were taking meat axes to people who were still alive in there. 
   (When my mother and a friend, both in their late eighties at the time, asked an assistant director of the program if they could peek into the area to get a sense of where they would wind up if they donated their bodies, they were harshly told that the department gets "requests each month from groups of high school students or boy scouts or even college classes.  To each and every one of these groups the answer is always no. Access to our facility is never granted." He later speculated that they were thrill-seekers with necro-porn motives, and added that the institution ia not "running an anatomy circus sideshow where anyone who wants to see a dead body can visit." He urged them to "pay for a ticket" and go see the "Body Worlds" exhibit. )

    Those who run the department say this cloak of secrecy is there  to "protect the privacy and dignity" of body donors. That, of course, isn't true -- they could simply cover the faces with a cloth if it were. They are protecting prospective donors from the extreme trauma of seeing what actually happens to donated cadavers. They don't want people running out of there screaming like hell instead of signing over their bodies. 

    For me, my father's death was a personal tragedy. His ongoing dismemberment is a nightmare.
   “Dismemberment” isn't my term. I have to give credit for that to a friend who graduated from medical school several years ago. He was so distressed by “what goes on” in an anatomy lab that when his mother died suddenly in her fifties, he overruled her signed contractual agreement to donate her body to a university medical school. "I couldn't stand it," he said, his eyes welling with tears. "Not my mother!"
    The phrase “rest in peace” has never meant much to me, but now I desperately want the medical school to finish with my father and let him do exactly that. Maybe he already is at peace, and I’m the one who is being ripped to shreds. In any case, I hope it will soon be over.

"The body is destroyed once the year is over," a Northwestern  medical student says.
      At the University, there is a "chronic shortage" of "cadaveric material" -- only about 85 donations on average are received each year from the entire Intermountain West, according to Kerry Don Peterson, director of the university's body donor program. This past year saw an unexpected and inexplicable increase to 148 bodies. Even so, "we can never get enough to fill our needs," Mr. Peterson says. Those bodies are shared with other institutions in the region. The university tries to increase donations by doing outreach through its positive relationship with donor families, conducting a well-publicized annual memorial service, collaborating with hospice groups, educating funeral service professionals and securing press coverage in regional newspapers.  

    Some cadavers are embalmed, so that they will remain usable over an extended time for teaching anatomy to medical students. Others are frozen (they can be refrozen and thawed up to three times) so doctors can use them for research and practice. Joints are often tinkered with, as new techniques are developed to treat or replace them. Brains are scrutinized in the quest to understand and treat Alzheimer's. Companies that produce medical devices can obtain access to cadaveric material as well, although it must involve the collaboration of a faculty member, according to Mr. Peterson.

    I thought it might be interesting to learn whether those who have worked with cadavers are more or less likely to donate their own bodies or to allow donation by their loved ones. I could only find two relatively small studies, but both showed conclusively that medical students’ willingness to donate their bodies plummets after their first exposure to the anatomy lab and remains well below 30 percent (even that figure is presumed to be inflated). Their willingness to allow loved ones to donate declines correspondingly. But the vast majority -- over 80 percent -- favor donation by strangers.
    At the University of Utah, about one doctor per year is among those donating his body, which is about three-quarters of one percent -- not exactly a stampede of former medical students ready to "give back."
    Students are reluctant to become emotionally involved in the donation process, and that defense mechanism remains with them throughout life, according to scholars at the Institute of Biomolecular and Biomedical Research. Several studies have examined the ways in which students "objectify" the cadaver -- regarding it as a "specimen" or a "thing" -- in order to cope with what for many is extremely and profoundly distressing. 
   Ironically, anatomists themselves aren't always keen to donate. Dr. James Williams, head of the anatomy program at Rush University, admits he's not yet registered. "I have mixed feelings about it, and I would say a lot of anatomists feel the same way." His colleague is also ambivalent. "Even if I were dissected I'm not sure I'd want the students here to do it. There is little privacy involved," he said
   I have also tried to find data on how body donation affects the grieving process of those who are left behind. Is it more protracted and intense than it might otherwise have been? Are there long-term effects, either conscious or unconscious, when a loved one's body is torn asunder? Is PTSD a possibility? A couple of academics refer to this issue in their writings, and acknowledge its importance, but neither explores it. 

    Presumably, most people whose loved ones donate their bodies have the ability and good sense simply to repress thoughts about the goings-on in the anatomy lab. I have always felt compelled to confront even the most disturbing things head-on. I don't know whether this is a character trait that could be regarded as a strength or whether it is merely dysfunctional and masochistic. I know it does damage to me, but I think repression does as well.
     There have been some rather tiresome studies about which racial, economic and geographical groups are more likely to donate. Other studies have classified the correlation -- or lack thereof -- between philanthropic giving and body donation, and between being a blood donor or an organ and tissue donor versus being a body donor. 
   Some studies even suggest that body donation is an egotistical act, to flaunt our decency, or an act to help compensate for hostile feelings that one has harbored through life.

   But none of these studies confronts the only question that matters: What are we afraid of? Why do virtually all of us refuse even to consider body donation?
     "What sorts of ethical appeals might anatomists, physicians, and other health professionals make to patients and family members for anatomical donation?" Richard Gunderman, asked in a 2008 journal article."Two models of giving, egoistic and liberal, merit close examination." He noted that medical education in Europe is threatened by dwindling body donations and predicted that the downward trend in the U.S. will continue.  
    A low-key, rational public service effort over the years has dramatically increased organ and tissue donation, but these are relatively delicate procedures which leave the body so intact that an open-casket funeral isn't precluded. Is it possible that a similar effort would demystify body donation, so that our future medical professionals could get the best possible education?
    An increasingly secular society appears to have played a part in the decline in donations, according to Geoff Rowley, a professor of orthopedics at Dundee University. "There's been a change in society," he writes. "There seems to be much more concern with how we treat dead people. We've moved away from the Christian ethic that when a body dies its soul leaves and you're left with an empty shell. You now get relatives refusing permission for autopsies with statements which are natural but illogical, like: 'My relative has suffered enough'."
    He predicts that the days when medical students spent a couple of years learning to take apart a cadaver are largely over.
    Professor Vishy Mahadevan, from the Royal College of Surgeons in Great Britain, agrees, citing  practical and educational reasons: “It is neither desirable nor feasible to go back to a situation where every student has their own body to dissect. It’s much more appropriate to have supervised prosection and anatomical teaching that is very clinically focused and relevant."

Sharing a cadaver to learn the intricacies of anatomy.
    One possible explanation for the shortage is that there is a long and grotesquely documented history of the abuse of cadavers -- entire photo books of students crudely messing around with them -- especially, of course, the female specimens.
    It has only been in relatively recent times that medical schools have begun making a concerted effort to prevent the abuse and disrespect of cadavers. Every director of a body-donation program with whom I corresponded emphasized that students are given strict guidelines about the handling of cadavers, and that they are encouraged to revere and respect the donor. I have read accounts by both doctors and medical students in which they described the relationship they developed with “their” cadaver. They express great appreciation for what they received and great affection for the person who enabled it.
   But the abuses continue -- just ask any medical student. They probably are uncommon, but I imagine a sort of “gallows humor” is widespread, not to disrespect the bodies but rather as a coping mechanism for the students, many of whom find dissection extremely traumatizing. More than one doctor has told me that his first cut into a donated body was the most memorable moment of his life. Even so, every person I know who has gone to medical school in the past 40 years has referred to cadaver-related "pranks" that aren't funny in the least. 
    Now that social media are available to broadcast one's antics, the medical schools can't keep this persistent problem a secret anymore. According to an anonymous survey of 78 U.S. medical schools published last year in the Journal of the American Medical Association, nearly 60 percent of medical schools admitted catching students posting unprofessional online content, including several blatant violations of patient confidentiality.
Austria Medical School
     This may be one reason that students don't plan to donate their bodies. But there is also the horror factor. Students refer to their "reverence" for the cadavers; they also mention nausea and nightmares after spending hours "up to their elbows in gore," according to an Examiner article.
     The shortage of donated bodies -- as well as financial considerations and time constraints -- have become so acute that many medical scholars are discussing the feasibility of teaching anatomy without them, and some already do, occasionally hauling out a plasticized cadaver to augment other teaching materials. Most academics, though, feel that the opportunity to work with a human cadaver is priceless in giving students both the knowledge of and feel for how the body works. But interactive technology is being developed that gives students such vivid and detailed  imagery, the use of cadavers may become less important.
    A smartphone application, developed in 2009 by researchers from the University of Utah, allows users to carry out a virtual dissection of a human body..The iPhone app, called "Anatomy Lab," provides images of a real human cadaver. It lets the user move between 40 body layers, zoom in to view different structures and rotate them to get different perspectives.
    Then there is the much more ambitious Visible Human Project, the world's first computerized library of human anatomy. Images of two bodies -- 1,800 thin cross sections of the man and 5,000 of the woman along with CT and MRI scans -- were created and stored in a computer at the National Library of Medicine in Bethesda, Md., accessible over the Internet.
    ''Quite a few people are suggesting that the Visible Human might eventually replace cadavers,'' said Dr. Donald Lindberg, the library director. ''With cadavers, you destroy the specimen as you dissect it, and sometimes you wonder if there were things you didn't see right at the beginning. With these computer images, you can reverse the dissection. You can go back and repeat your study.''

    Even so, as a patient, wouldn't you rather have a surgeon who has had some major practice with the scalpels, and whatever else all those instruments are? Wouldn't you want a doctor who knows intimately, through touch and first-hand explorations, the inner mysteries of the body? The whole cadaver biz gives me the creeps, but it does seem worthwhile.  

   In a January 2011 paper entitled "A proposal for a policy on the ethical care and use of cadavers and their tissues," Thomas Champney urges that, "The use of the body should be made clear to the donor and the family in the consent form. If the body is to be used solely for the education of medical personnel, this should be stated with a general description of what occurs and the proposed time frame for the use of the body. If the body is to be used for tissue collection, for research or for other purposes, this should also be stated with a general description of the time frame and the process. If any remuneration for the use of the body (transport fees, handling fees) or for the use or procurement of tissues or organs occurs, this should be stated in the consent form."
    This seems like a modest enough proposal, but it has not been adopted.

     Kerry Don Peterson is the director of the University of Utah body donation program. He loves his work, loves the students and loves the donors who make such a priceless contribution to medical knowledge. One might expect to find such a "let it be" and "peace be with you" sort of person running a yoga studio, blissfully cultivating an organic garden or selling T-shirts and "smoking paraphernalia" in a way-cool Haight-Ashbury shop. He is an expansively loving man, whose perspective ranges from the starry spheres of the astronomical to the most minute particles in creation. Somewhere in there, he says, he has discovered a place where a soul might reside. 
    He says he likely won't donate his body to science. He's been with the University of Utah program for 26 years (and he was a mortician before that), so by the time he retires, he says, "I will probably want my body to have a new venue, with some better scenery."

12/12/12: The portion of my father's cremains that is not in my possession was interred today at the Salt Lake City Cemetery donor plot. I am so glad that I have my allotment with me. The handsome box weighs two or three pounds. On top, I have placed Daddy's eyeglasses, and one of his most treasured reference works, "The Rare Metals Handbook," which was published in 1954. While I am reading or watching TV, I often reach over and place my hand on the box, as if for mutual companionship and reassurance. Sometimes, I just hold it to my chest, put my head down, and cry. I suppose this sounds a bit morbid to some people. It isn't to me.

An excellent NPR series: