Ceremonies of gratitude following the dissection course: A report on procedures in departments of anatomy in German speaking countries

Abstract

The departments of anatomy in Germany, Austria and the German-speaking part of Switzerland were sent comprehensive (18 items) questionnaires requesting details on memorial ceremonies held at the close of the dissection course in the medical curriculum, including objectives, organization, number of participants and the role of the medical students. The response rate was very high (95%). In more than 95% of instances a ceremony is held, initiated mainly after 1970. The titles of the ceremony range from commemoration ceremony (42%), service of mourning (19%) memorial service (19%) to ceremony of gratitude (7%). The number of participants exceeds 300 in 15% of these ceremonies. The invitation comes mostly from the student group organizing the ceremony (62%). The ceremony is offered mainly for the students of the course (23%), for student tutors (16%), relatives of the body donors (23%) and scientific staff (15%). The students actively participate with musical contributions (19%), gestures such as candles (17%) and flowers (12%), speeches (17%) and readings (12%). The relevance of the practical dissection course and body donation programs is also discussed. The results are compared to ceremonies in various countries with different religious backgrounds. This dissection course is unique among all courses in the medical curriculum as it obviously also has spiritual aspects.

Introduction

For generations the dissection of human corpses had been taken to be essential in undergraduate medical education (Putz, 1999, Weiher, 2000). In recent years the relevance of this course has been either questioned (e.g. Nnodim, 1990, Mc Lachlan et al., 2004, Lippert, 2012) or strongly supported and its relevance stressed, despite the costs of maintaining a dissection room and the other infrastructural measures (Older, 2004, Biasutto et al., 2006, Winkelmann, 2007, Korf et al., 2008, Boeckers et al., 2010a, Ochs et al., 2012). When young medical doctors were asked in their specialization examination (e.g. surgery, pediatrics) to grade all compulsory courses in the undergraduate curriculum with regard to their relevance for medical practice, they placed the dissection course at the top of the list, higher than pharmacology or internal medicine (Pabst and Rothkötter, 1997, Hofer et al., 2006). Marom and Tarrasch (2015) also stressed the relevance of the dissection course, based on a survey among medical students, residents and specialists in Israel. Other authors have argued that the importance of the dissection course must be seen not only in the learning of anatomy, but also in the fact that it comprises the first examination of a human body and strengthens team competence through cooperation with fellow students (e.g. Lempp, 2005, Korf et al., 2008). Orsbon et al. (2014) argued the relevance of medical imaging and called for a vertical integration. As early as 1986, a recommendation was published not to discontinue dissection but rather to integrate surface anatomy (“living anatomy”) and radiology (Pabst et al., 1986). Boll et al. (2011) recommended “the body as a teacher” in contrast to “the body as the first patient” as this stressed a closer relationship, enduring empathy and respect for the donor and future patients. Although many arguments for and against compulsory dissection courses for medical students have been presented, no scientific studies have been conducted as to whether they contributed significantly to the qualification of medical doctor (Winkelmann et al., 2007).

Human bodies are needed for the dissection course. From the thirteenth to the early seventeenths century the bodies of executed people were the only legal source (Hildebrandt, 2008). Later, unclaimed persons were also made legally available. Body donation programs were started much later (Becker et al., 2012). In a series of papers, Sabine Hildebrandt documented the procedures of anatomy departments in Germany during the National Socialist regime (Hildebrandt, 2009a, Hildebrandt, 2009b, Hildebrandt, 2009c). Hildebrandt, 2010a, Hildebrandt, 2010b, Hildebrandt, 2013 also described research on the bodies of executed persons, as published in anatomical journals from 1924 to 1951. It took some time until the Anatomische Gesellschaft organized a symposium on this topic in order to elaborate a position of critical approach to this period of German anatomical institutes (Hildebrandt, 2011, Hildebrandt and Redies, 2012, Winkelmann, 2015). The ethical aspects of the role of anatomists in Germany should continuously be discussed within the lectures, seminars and courses for the medical students. As in other countries, the human bodies for the dissection courses are donated by people who sign a voluntary will to donate their body for the purposes of teaching, research as well as the training of surgeons and other clinicians (Boeckers et al., 2008). As yet, we have not been contacted by Muslims with regard to body donation. This could be due to the fact that organ donation −but not body donation- is recommended in Islam-oriented medicine (Al Masri and Walter, 2013).

The causes of death of body donors in other countries correspond to those in Germany (Konschake and Brenner, 2014). In the past it was reported that body donors of the Medical School Hannover were to be found in all social classes (Lippert et al., 1980). However, there were approximately 10 times more body donors who were not members of a Christian church. There are no more recent studies examining the religious background of body donors known to us.

Although body donors in Germany have to contribute to the costs incurred (e.g. transport of the corpse to the anatomy department, cremation of the remains after the course and cemetery burial) there is no shortage of donors (Becker et al., 2012). In Germany the “Bestattungsgesetz” (burial laws) regulates the procedures to be followed in dealing with the corpses. These burial laws differ somewhat for each of the 16 federal states.

One question repeatedly asked by the students is that of organ donation versus body donation. In Hannover, organ donation always takes priority over body donation. The age of organ donors is constantly increasing (Becker et al., 2012, Konschake and Brenner, 2014) and therefore, all anatomy departments should stress the preference of organ donation in the body donation protocol. This aspect is of growing relevance because the age of organ donors and organ recipients has increased very much over the last years (e.g. see Tulius and Midford, 2011, Heinbokel et al., 2013).

Many students experience problems in dissecting a human corpse. Various groups have advocated psychological advice and help prior to or during the course (Shalev and Nathan, 1985, Tschernig et al., 2000, Lempp, 2005, Bernhardt et al., 2012;Weyers et al., 2014; Beerheide, 2015). The dissection course also has a spiritual aspect (Putz, 2011; Marly et al., 2012; Shiozawa et al., 2015). Belief in the soul influences the amount of stress experienced by the students in the dissecting lab (Martyn et al., 2014). In the course of their training, medical students must not only learn anatomical facts, but also be confronted with the ethical aspects relevant to a physician’s daily work (Boeckers et al., 2010a, Boeckers et al., 2010b). This was also recently recommended for Germany by the National Competence Based Catalogue of learning (http://www.nklm.de).

The Medical School Hannover has followed a stepwise approach for many years as the students are confronted with dissection as early as in the first weeks of their curriculum. The course lasts for 2 semesters. During the first week of the curriculum the students are shown the dissection halls but without the presence of any corpses. At the beginning, a conserved cadaver is shown in the lecture hall and the signs of death such as rigor and cadaveric ecchymosis are explained. The students are furthermore expressly advised to discuss any upcoming uneasiness with their fellow students or tutors in the respective dissection hall. There is hardly any smell of formaldehyde in the Hannover dissection hall as ethanol is mainly used for fixation of the body. On the first day, the students are encouraged to debate the probable age, profession, etc. for example, by examining the hands of their body donors. For the first week, a representative of the Protestant and Catholic student clergy is present for any consultation or counselling in the dissection hall. Recently, a further meeting with all students has been offered in the evening. For several years, seminars have been organized after this first course to discuss potential difficulties in the dissecting of a dead body. No student has ever been ex-matriculated as a result of problems with dissection. At the beginning of the second semester, an announcement is made that a ceremony in honor of the body donors will take place at the end of June. Volunteers and clergy form a group to organize it. They take care of all arrangements such as the music to be played, the speakers and the prayers. The Protestant or Catholic clergy merely participate and moderate but do not decide on details. The degree of emotional involvement displayed by the students and other participants is very impressive. Some female students who have attended the ceremony wearing scarfs are presumably Muslim. The chapel of the hospital is always overcrowded, one indication of the fact that the medical students are extremely grateful to the body donors.

There are different body donation programs in various countries. It is interesting to note that, depending on country and culture, there are varying ceremonies carried out by the students to express their appreciation, such as in Germany (Tschernig and Pabst, 2001, Pabst and Pabst, 2006, Pabst, 2007, Eggers, 1998). Similar studies have been published for various countries: The Netherlands (Bolt, 2012a, Bolt, 2012b, Bolt et al., 2012), USA (Elansary et al., 2009), China (Zhang et al., 2008, Zhang et al., 2014), New Zealand (Cornwall and Stringer, 2009, Jones and King, 2016) and Thailand (Winkelmann and Güldner, 2004). In Thailand there is a ceremony at the beginning of the course and a second one at the end of the course (Winkelmann and Güldner, 2004). In Vietnam (Ho-Chi-Mink-City) the medical students not only decorate the walls of the dissection room to honor the body donors but also the cadavers are adorned, e. g. with flowers around their heads (M. Ackermann, Mainz, personal communication 2016).

Some years ago we asked anatomy departments in Germany whether they offer a ceremony after the dissection course (Pabst and Pabst, 2006, Pabst, 2007).

In recent years the percentage of the population in Germany who are members of the two main Christian denominations has decreased continually: Catholic 30%, Protestant 28% in 2013 (Statistisches Bundesamt, 2015). Participation in Sunday services also fell in 2013: 10.8% for Catholics and 3.3% for Protestants (Statistisches Bundesamt, 2015). In 2014, we, therefore, sent the same questionnaire to anatomy departments in Germany, Austria and the German-speaking area of Switzerland, with a request for information such as title, organization, number and background of the participants as well as details of these ceremonies. A central aspect of this study has been a comparison of the involvement of Christian clergy, the title of the service and the current number of participants with the previously obtained data.