Speaking for the Dead: Cadavers in Biology and Medicine. Jones, D. Gareth. Aldershot, Hants, England: Ashgate Publishing Co. Ltd., 2000. viii + 275 pp. $89.95.
Although this book casts a wide bioethical net, it is reviewed in the Journal because of its relevance to a major emotional landmark in the training of physicians. Memories of their initial encounters with cadavers in the dissecting room (often focused mainly on the one they, themselves, dissected, referred to possessively as “my cadaver”) are typically among physicians’ most vivid recollections of their medical student days. Among the remembered fragments are those of the feel of the body’s hands, speculations about “who” the dead person was, thoughts about the morality of this type of disposal of human remains (coupled with reflections on leaving one’s own body to “science”), and recognition that the occasionally crude humor and mutilation of the cadaver engaged in by some students may have represented their attempts to deal with uncomfortable feelings about the situation. Some psychoanalysts will remember Robert Fliess’ suggestion that medical training is antithetical to personal development as a psychoanalyst because the future analyst’s first “patient” is the irrevocably passive cadaver. This has been used as an argument in support of Freud’s position that psychoanalytic practice should not be the exclusive prerogative of physicians and recognition of the possibility that physicians may, by virtue of their educational experience, be less suited to become psychoanalysts than psychologists, social workers, humanity specialists, or artists.
Medical school teachers, including anatomists (perhaps anatomists least of all), have long recognized the unexamined emotional as well as ethical issues surrounding human dissection, and the desirability of helping the fledgling doctor confront them. Only a few, however, have tried to introduce some systematic early education about them. In a few settings, small group discussions have appeared to be fruitful stimulants of thought about the nature of the student-cadaver encounter and protection against its emotional impact. But there have been no texts to guide professor or student. Now, D. Gareth Jones, Professor of Anatomy at the University of Otago in Dunedin on the South Island of New Zealand, has begun to fill the void with what promises to be a comprehensive text on the matter—but which in its latter chapters focuses more intently on organ transplantation, brain death, and research on embryos, issues that are conceptually relatable to cadavers, and are socially and politically important in today’s bio-ethical scene, but are removed from the beginning students’ first encounters with the cadaver.
Jones’ overall orientation is revealed in the book’s title as well as its preface: he speaks for the dead, even, in a sense advocating for them, with his purview including organs, tissues, and embryos, as well as adult bodies. He believes that how people respond to “the dead” as well as the use made of their remains, and what may be learned about ourselves by studying them, raise ethical questions “that go to the heart of what it means to be human.” His volume, thus, is not aimed narrowly at medical students and physicians and, in his words, is devoted to an exploration of the “many links between the living and the dead.” This is an enterprise that, depending upon the reader, might be perceived as having societal, cultural, and even religious overtones. Indeed, it is the kind of book that might be expected to appeal more to the general, mature, reflective reader than to the hurried, concretely oriented contemporary student of medicine.
Chapters 1 (“Cadavers as Images of Ourselves”) and 2 (“History and Contemporary Ethos of Dissection”) offer an interesting introduction to what Jones terms “the culture of dissection” with due, although brief, references to ancient and medieval history, ethical and legal concerns, and human remains as artistic objects. Only three pages in chapter 2 give a partial review of the literature on students’ experience of dissection. The published reports suggest that some British and American students have adverse (“traumatic”) emotional reactions to their close encounter with a cadaver but that, except in rare instances, they are rather quickly resolved without therapeutic intervention. In contrast, at least 25% of Nigerian students, according to one report, were greatly distressed by the dissecting room experience. But even in the British and American settings, the data may be taken to suggest that some systematic attention to their emotional involvement and moral concerns, even for students who keep it to themselves, might increase later empathy with living patients.
My own experience as a psychoanalyst with several autopsy pathologists as patients suggests that constant immersion in the world of dead bodies, with the repeated experience of deconstructing them, had a profound effect on their inner lives, even though it did not fit the category of “trauma.” Of course, these were people whose discomfort (not immediately focused on their work) was sufficient for them to seek analytic treatment. Their choice of pathology as a medical specialty may also have been influenced by idiosyncratic attitudes toward corpses and death antedating their medical education. At least one could be characterized as having necrophilia.
Chapter 3 (“Acceptable and Unacceptable Uses of Cadavers and Tissues”) deals with the possible abuse of cadavers, ownership of tissues, the place of autopsies in the world of medicine, the importance of obtaining consent for autopsy from relatives, and, at some length—though, essentially, at a literature review level—with the ethics of human experimentation as practiced by the Nazis and Japanese. It is no surprise that a New Zealander mentions the concerns of the Maori (who constitute approximately 12% of the country’s population) for the integrity of the bodies of their dead relatives; more of a cross-cultural nature would be welcome. The discussion of consent for autopsy would be more useful for teaching if it recognized the possible discomfort of physicians in training who are sometimes given the responsibility of obtaining such consent. Among my more uncomfortable memories of a 1944 externship in a cancer hospital was being required to obtain such consents with insufficient advice about dealing with families and even about the reasons why autopsy was desired.
Cultural issues, in this case related to research in archeology and physical anthropology, are more prominent in chapter 4 as indicated by its title “Human Skeletal Remains: When Indigenous Concerns Conflict with Scientific Aspirations.” The Maori, like the Native Americans of the United States, are becoming more assertive in regard to the disposition of their skeletal remains and related artifacts, some of which have been in museum collections for generations.
The final three chapters of Jones’ volume leave the autopsy room for concerns more relevant to practitioners and ethicists than to beginning medical students: organ and tissue transplantation and brain death. The final chapter deals with the “pre-embryo” and the concept of “brain birth,” which “has featured in attempts to elucidate a moral point-of-demarcation prior to which experimental procedures may be undertaken on human embryos but after which they are forbidden” (p. 227). These two themes address the same question: “When, on the basis of biological information, does the early human individual acquire moral significance?” (p. 228). The answer to this question does not preclude, for Jones, research on embryos. He proposes that “ethical principles should be formulated within a context provided by viewing the human embryo as a proto-cadaver. We may then find that some of the important historic debates on adult cadavers will have to be revisited in the embryonic area” (p. 246).
This book is a potentially useful contribution to medical education. It would be more useful if it contained a more direct and extensive treatment of the emotional impact of the dissection experience on student and practitioner. Some social scientists have tried to interest students in the hidden biographies, interpersonal and sociocultural, of the cadaver, which was once a living human being. Humanists have also participated in such teaching, bringing in related materials from fiction and poetry. The first chapters of this book could provide a framework for such teaching. The relevance for the student of the later chapters on ethical considerations in organ and tissue transplantation, brain death, and the status of embryos is less certain. Perhaps they would be more useful in the context of a thorough-going examination of contemporary bioethical issues, including those associated with the exploration and manipulation of the human genome.