BOOK REVIEW
Speaking For the Dead: The Human Body in Biology and Medicine
D.
Gareth Jones and Maja I. Whitake
Farnham:
Ashgate Publishing Ltd, 2nd ed., 2009, 238 pp, £65, ISBN
978-0-7546-7452-8 (hbk)
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DOI:
10.2966/scrip.070210.414 |
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For those, like the present reviewer, who have not read the first edition, the title of this book raises intriguing possibilities. The work forms part of a series entitled Medical Law and Ethics. Is this, then, to be an analysis of the rights of the dead body and the dignity it attracts or should attract as is suggested in the main title? Speaking as a one-time pathologist, I have always been surprised at the minimal interest attached to these questions in the medical curriculum. Is this monograph going to fill what I see as a yawning gap in medical ethical education? Quite clearly, there is an intuitive societal anxiety to show due respect for the dead – there would have been no need for the trade of grave-robber had it not been for the determination of the bereaved to protect the bodies of the deceased from the maw of the dissecting room. Moreover, this sensitivity is neither confined to close relatives nor is it independent of the circumstances. Again, one can attest personally to a wholly different reaction to dissecting already preserved and processed human remains in the anatomy school as a medical student and performing much the same task in the autopsy suite as a pathologist where the tissues under investigation are no longer “remains” but, rather, constitute a “person” making his or her last contact with the world of the living. Yet the subject, in each case, is a human body and to distinguish the two in any way is, on the face of things, illogical. Will this book answer the question of whether one’s contrasting reaction is rational or irrational?
Certainly, the Preface with its heavy emphasis on the application of ethical principles to the work of anatomists indicates that this is the chosen path. The list of contents, on the other hand suggests a descriptive analysis of the dead body in eight distinct configurations and one wonders if the text, rather than speaking for the dead, will, in fact, be speaking of the dead? Or will it, rather ambitiously, attempt to do both? Such musings were sufficient to set me on my way with great expectations of what was to come.
The very first page emphasises the authors’ moral sensitivity when approaching their task and chapter 1, as a whole, illuminates its breadth. The question – what do we mean by “the body”? – opens innumerable channels for both philosophical and factual discussion. As to the former, Professor Jones lays out his stall very early – human remains “can never be completely dehumanized” – and, as a consequence, a body is always “somebody’s body”. And, leaving aside the question of the dignity that body should attract, that raises practical issues as to ownership which resonate in parallel with advances in molecular cellular anatomy and the potential commercial opportunities they provide. In short, one thing leads to another and perhaps the major message of the book is that “anatomy”, in the broad sense adopted, does not end in the dissecting room. Even so, it starts there and the authors admit that it remains replete with nineteenth century connotations. The book, therefore, rightly starts with an analysis of the culture of dissection which originates from its close association with public executions followed, indeed, by the concept of the dissection itself being a matter for public exhibition. The chapter takes us through the centuries and the associated changing public attitudes and leaves us with the impression, as exemplified by the non-consensual retention of aboriginal remains, that conflict between scientific and philosophical disciplines is still real – anatomy, using the word in its widest sense, is only acceptable when “it fits within the expectation of a particular culture”. Chapter 1 is, effectively a résumé of what is to come and the authors very neatly find the source of the ethical arguments to be deployed as lying within the way in which bodies are obtained for dissection.
It is, therefore, right that Chapter 2 takes us from the notorious duo of Burke and Hare, through the early British Anatomy Acts, to the English Human Fertilisation and Embryology Act 2004.1 This is followed by a description of the necessarily fragmented position in the United States – where, interestingly, the continuing association of anatomical dissection with poverty is noted – and, of course, of that in Australia and New Zealand, which was designed, largely, on the British model. More importantly, however, the authors take a long look at the reasons why people will bequeath their bodies for dissection, this being, now, the virtually sole source of what many of us would still see as an essential teaching resource. The significance of altruism and the underlying conflict with the use of “unclaimed bodies” is discussed, essentially under the rubric that how bodies come to be in the dissecting room cannot be dissociated in ethical terms from how others arrive in the transplant operating theatre. While one wonders if this is so – and particularly when considering family interests in the disposal of a body - it has to be remembered that Jones and Whitaker see this as a “fundamental concern of this book” and that this is maintained in subsequent chapters.
Yet, while running the risk of being subjective, this reviewer cannot help feeling that there is a greater distinction to be made between the role of the anatomist and the pathologist than they imply. There can be few coroners’ or fiscals’ pathologists who do not develop some distaste for their job towards the end of their careers which must derive from a growing empathy with their relatively supple, naturally coloured subjects whose history they may know only too well. The anatomist, by contrast, appears able to regard dissection as a purely scientific exercise from which he or she can dissociate in an emotional sense. This reviewer is, therefore, somewhat surprised at the work of Carter, which is quoted extensively, as to the “intimacy” between students and the anatomised cadaver. Certainly, this is one area here this book has forced me to stop and think. Were we more insensitive than our grandchildren are? I don’t think so but it would, nevertheless, be interesting to read of a comparable review of doctors at the time of retirement. I have a feeling it would demonstrate a comparative change of attitude which is, of course, impossible in a student survey. Interestingly, this concept is taken up and crystallised in Chapter 4 – “The Plastinated Body” – where it is suggested, with good reason, that the overriding impression of the dissecting room derives from the smell of the fixatives used; the comparator in the mortuary is the smell of decomposing human bodies.
Somewhat strangely, the chapter concludes with an extensive review of the more recent scandals relating to the disposal of body parts, ranging from those of a clearly scurrilous nature to those which demonstrate a failure to balance the enthusiasms of research against respect for the dead body and for the sensitivities of those close to the body in life. This, one feels might more logically have been incorporated in the next chapter – “The Abused Body”. Here, the fundamental questions lie in whether the cadaver can be mistreated and, if so, whose interests are engaged when this occurs? Again, the authors force the reviewer to rethink issues to which the answers had, perhaps, been previously regarded as self-evident. The use of the dead body for both clinical training – the so-called neomort - and scientific research is considered and the reader must decide whether he or she is satisfied by the somewhat pragmatic approach to kindred consent that is adopted. It has always seemed to me that, if the dissecting room and the mortuary do pose a threat to the dignity of the human race, then it is the dissection itself that provides the insult. An ethical distinction must be made between research carried out as part of the dissection and that which uses the cadaver as a poor substitute for the living body and which has no close relationship with the individual cadaver – e.g. to establish the force needed to penetrate the skin with a knife using a body that has died from natural causes. This is, to some extent, reflected in the current legal emphasis on the approach to the autopsy; the anatomist has been subject to a licence to practice for almost a century – it is only since the passing of the Human Tissue Act 2004 that the same has applied to the pathologist.
The need for and use of dead bodies as models for teaching morphology and improving clinical skills has, of course, been revolutionised by modern electronic and plastic technologies but, even here, we are not out of the ethical woods. There is a world of difference between a plastic model and a body that has been plastinated – in which human material is integrated with plastic, thus improving its consistency and its natural appearance. The authors imply that this need not, per se, be a cause of controversy nor of general public interest – but is that so? Plastination would surely need to be taken into account in deciding if donation of the body and its parts were to be accomplished under the anatomic or medical provisions of s 1(1) or 1(2) of the Human Tissue Act 2004. More importantly, perhaps, it lends itself to the commercialisation of the human body by way of exhibitions. The ethical implications are widespread and deserve the considerable proportion of Chapter 4 that they occupy; irrespective of these, Chapter 4 contains much factual information of which few outside the closed world of anatomy will be aware.
And so to “The Transplanted Body” which is not, as might have seemed reasonable, concerned with burial and exhumation. Rather, it is at this point that Speaking for the Dead begins to move away from the interests associated with the cadaver and to engage with those of the living. The authors acknowledge this but, while, being anatomists, they introduce discussion based on anatomical – e.g. hand or neural tissue – rather than organ donation, this chapter adds little to the existing discourse – nor would one expect it to do so given the title of the book. The concept of the cadaver as a source of life-saving devices is an exception and one might have wished this to have been used as the primary peg by which to integrate it within the general philosophical framework of the book.
However, we return to the mainstream with a bump in Chapter 6 – “The Indigenous Body” – which, in essence, discusses the human body in terms of archaeological research and its conflict with the descendants of the research subjects. The political and other non-medical issues raised are far reaching and it is interesting to reflect on and compare the furore surrounding retention of cadaver tissues that arose world-wide in the 1990s with the casual attitudes adopted by the “body-snatchers” of previous centuries. The title of the chapter is, perhaps, a pity. This reviewer believes that it might have been better to see discussion of the “indigenous” body as being but one aspect of the respect due to human remains per se – that is, those which have ceased to have any relationship with the living. Even so, it is a stand alone chapter which should be read for its own sake; the authors take what could be described as a brave stance in the present social climate.
And so to “The Developing Body” which I had been looking forward to not only in the light of Professor Jones’ published views on the status of the embryo but also because its inclusion in this book must be the most difficult to justify. In the end¸ I came away disappointed. The “symmetry between brain birth and brain death” is scarcely revisited and it remains unclear why research on embryos – no matter how they have originated – should be singled out for discussion any more than research on any other forms of living human tissue. Having said that, Chapter 7 is as good and as fair as any succinct appraisal of the moral status of stem cells, embryos and early fetuses as one is likely to find. It sits uneasily, however, with the remainder of the book and the authors, themselves, acknowledge this in their introduction. Much the same, though to a lesser extent, applies to “The Thinking Body” in Chapter 8. Certainly, brain death and its distinction from PVS is eminently suitable for discussion when speaking for the dead2 but a high proportion of the chapter, as is to be expected from this source, is devoted to clinical neuroanatomy and neurophysiology and, interesting though it is, it is at risk of being seen as misplaced – and particularly so when items such as lie detection are introduced. Indeed, one might go further and critically question the implied derivative association between brain death, PVS and Alzheimer’s disease at p 207 – are we not coming dangerously close to the infamous slippery slope? By and large, I would like to see this chapter recast under the title “The Diagnosis of Death”, the implications of which, in my view, merit greater all round attention than the book provides.
And so to the final chapter – “The Modified Body” – which I have to admit was a major disappointment. Rather than being a summation of the anatomist authors’ views on our duties to the dead, it flies off at a tangent and is undeniably devoted to the treatment of the living body – a fault which lies at the heart of any criticisms of what is elsewhere a very interesting book. In essence, I feel that the book, as it stands, would be more accurately described under its sub-title – or, alternatively, under a modification such as Speaking of the Human Body. The authors freely admit to a move from the cadaver to the living body at Chapter 7 and one gets the feeling that this was what they intended – the chapter headings themselves, described as “body-based” at p 191, go some way to supporting this view.
Even so, there is a real need for a book devoted to the ethico-legal obligations to the dead – as has already been said, the title itself strongly attracted this reviewer - and Speaking for the Dead, rightly written from the modern anatomy department, deserves the benchmark position in the milieu. I firmly recommend it for those engaged in the medico-legal, bioethical and general philosophical arenas – not forgetting the medical student curricula. There are deficiencies. As I have mentioned, consideration of the diagnosis of death and the disposal of the dead in general is surprisingly sparse. I personally think there is a greater distinction to be made between the anatomists’ and the pathologists’ interests in the body than the authors would have us believe and I think there is a special need for a look at the coroner’s role in disposal of the dead; the uniquely cavalier approach of the legislature to the ethics of the medico-legal autopsy has long been ignored in the United Kingdom – though not, I believe, in the Antipodes. It is, indeed, salutary to reflect on how much views such as those expressed in Speaking for the Dead have influenced the drafting of the new English Coroners and Justice Act 2009.
Prof Ken
Mason
School of Law,
University of Edinburgh
©
Ken Mason 2010
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1 Although it is a somewhat parochial criticism to introduce, I do not think it is clear at p 28 that the Anatomy Act 1984, as amended, remains in force in Scotland. This is of some importance to the text in that the concept of “authorisation”, which is noted with approval, does not apply to anatomical dissection.
2 However, it is difficult for a UK observer to accept that the legality of withdrawing treatment from PVS patients is questionable since Airedale NHS Trust v Bland [1993] 1All ER 821 and its associated cases.