Formal body bequest program in Nigerian medical schools: When do we start?
Human body dissection is a prerequisite for the training of health professionals and the conduct of medical research. However, most Nigerian medical schools experience difficulty obtaining an adequate and regular supply of human tissue. Presently, the major source of anatomical material comes from unclaimed bodies collected from hospital mortuaries. However, one sure way to ensure a regular supply of bodies for anatomical dissection is to establish a whole body bequest program among the departments of anatomy in Nigerian medical schools. If such a program were to be supported by an appropriate legislative act of parliament, the supply of acceptable cadavers for anatomical teaching and research would be substantially increased. The author advocates for establishing a whole body bequest program among Nigerian medical schools. Anat Sci Educ. © 2011 American Association of Anatomists.
Anatomy is the foundational discipline of medicine and the allied health professions (Older, 2004; Sugand et al., 2010). To achieve a proper understanding of the fabrics of the human body, cadaver dissection is essential. A recent study of Nigerian medical students' attitudes to dissection carried out at the Ambrose Alli University in Ekpoma revealed that 90% of students considered cadaver dissection to be an important and indispensable component to their study of human anatomy (Izunya et al., 2010). Indeed, most medical schools across the globe still maintain the practice of cadaver dissection (Kramer et al., 2008; Drake et al., 2009; Sugand at al., 2010).
To keep this tradition of body dissection alive, a regular supply of cadavers suitable for educational dissection is prerequisite. In most African countries, including Nigeria, cadavers are usually sourced from hospital mortuaries. These largely consist of cadavers unclaimed by the deceased individual's relatives (Gangata et al., 2010). Cadavers sourced from felons are likewise accepted into the gross anatomy dissection laboratory, although certain tissues may not be intact or undamaged, thereby making whole body educational dissection impossible. With regard to those bodies sourced from hospital mortuaries, departments of anatomy often encounter shortages. Mortuary attendants often retain unclaimed bodies on the grounds that relatives of the deceased may come for them at any time. Moreover, even when these bodies are released to departments of anatomy, the tissues may not be well preserved or intact (having missing or damaged body parts). Within these constraints, gross anatomy laboratories in Nigerian medical schools are often faced with an inadequate supply of cadavers for anatomical teaching and research.
BODY BEQUEST PROGRAMS
The concept of voluntary body donation is alien to Nigerian society, unlike in other regions of the world where it is relatively accepted (Izunya et al., 2010). In many countries outside Africa, challenges associated with a regular supply of suitable cadavers have been largely surmounted by the establishment of body bequeathal programs (or willed body programs). Liles and Ross (1998) indicated that in the United States ∼85% of bodies for anatomical dissection are received from willed body programs, and the remaining 15% were donated by family members. They also determined that only 20% of institutions were willing to accept unclaimed bodies for medical education programs (Liles and Ross, 1998). Similarly, anatomy departments in Korean Universities have achieved a regular supply of human tissue for teaching and research by establishing successful body bequest programs (Park et al., 2011). The same is true in Europe, where appropriate legislation is in place to support willed body programs (Gunderman, 2008); presently, all cadavers used in the United Kingdom are donated (Stott, 2008). At the University of Otago in New Zealand, the Anatomy Department now receives more than 40 human body donations per year; this makes body sourcing for anatomic purposes considerably easier (Cornwall and Stringer, 2009). This suggests the need for each department of anatomy to establish and sustain a body bequest program.
SITUATION IN NIGERIA
However, in most of sub-Saharan Africa and Nigeria, a formal willed body program is unavailable in most anatomy departments despite an inadequate supply of suitable human tissue for anatomical dissection and the challenges associated with sourcing human tissue for this purpose (Gangata et al., 2010). It is therefore essential for departments of anatomy in Nigerian medical schools to establish body bequest programs to achieve a regular supply of suitable cadavers. To do this, each university council must approve and support the establishment of a body bequest program for the anatomical sciences. More importantly, the state and/or federal legislature should enact a law in support of donation programs similar to laws enacted in the United States (UAGA, 2006), United Kingdom (Human Tissue Act, 2004), New Zealand (Human Tissue Act, 2008), India (Anatomy Act, 1957), or Australia (Human Tissue Act, 1982). If such a law were in place, public body donation centers could be established in major cities for easy collection of willed bodies after the death of donors. Without such a legislative act, establishing these public centers would be practically impossible. In developed countries, successful body bequest programs are supported by federal legislation (Hutton, 2006; Taylor and Wilson, 2007; McClea, 2008; De Caro et al., 2009).
In 2007, the Lagos State House of Assembly passed an executive bill referred to as the Lagos State Coroner's Law, which was endorsed by the State Governor (Odebode, 2008). In the present form, this legislation does not facilitate body acquisition for anatomical science; in reality, it has the opposite effect by significantly reducing the number of cadavers available to medical schools for anatomical education and research. Section 14 of this law makes autopsy mandatory for all deaths of unknown causes. This has an adverse effect on the education and training of health care professionals, especially medical doctors. Presently, Nigerian medical schools receive most bodies for anatomical dissection from hospitals. However, subjecting all deaths that occur in hospitals to autopsy would create a shortage of bodies destined for educational dissection, as those that undergo autopsy are no longer suitable for teaching anatomic structures and their relationships.
In addition to legislative requirements to initiate a bequest program, potential body donors must be motivated by altruism (the wish to be useful after death), as well as other personal benefits (Gunderman, 2008; Bolt et al., 2010). In the past, grave robbers and slave owners were motivated by profit in selling bodies (Halperin, 2007). Even today, some families choose to provide bodies to help pay for funeral expenses (Gunderman, 2008). To establish a successful bequest program for anatomical sciences and medical education, anatomists must demonstrate prospective donors how body donation promotes their own self-interest. As Gunderman (2008) indicated, this appeal could take several forms: (1) if members of the public do not encourage others to donate, they, too, may someday suffer unnecessarily from a disease or injury that could have been prevented or effectively treated if only more people had donated their bodies; (2) by donating one's own body, a person has the opportunity to impress others with his or her generosity and enlightened attitude toward death; and (3) donation will make the donor feel good (Gunderman, 2008). Anatomists, students, and other trainees must serve as models to the public in their willingness to be enlisted in bequest programs at their respective institutions. Studies show that the attitudes of anatomists, medical students, and health care professionals toward donation of their own bodies vary around the world (Arráez-Aybar et al., 2004; Sehirli et al., 2004; Cahill and Ettarh, 2008; Perry and Ettarh, 2009).
It is understandable that such bequest programs cannot be created simply by enacting the appropriate legislative acts. It would also require time for the public and society to see the benefits of body donation. In the meantime, the Nigerian state and/or federal legislatures should also consider enacting laws that will enhance the acquisition of unclaimed/abandoned bodies from hospital mortuaries. Similar to existing laws in other countries, that is, India (Anatomy Act, 1957), Nigerian legislation should provide clear provisions and specify a legal time frame for bodies to be retained in hospital mortuaries, beyond which unclaimed cadavers should be released to the jurisdiction of appropriate authorities for transfer to departments of anatomy. This would confer legal umbrella protection of both hospital management and anatomy departments from potential lawsuits brought by the relatives of individuals whose bodies were unclaimed.
CALL TO ESTABLISH BEQUEST PROGRAMS IN NIGERIA
As commendable and desirable as whole body bequest programs in Nigerian medical schools would be, there are challenges. One such challenge is that the Nigerian populace is not aware of the need for whole body bequests. Indeed, body donation is an alien concept to Africa. The people must therefore be enlightened (perhaps through broadcast media, print media, etc.). Several studies examined the impacts of different media in distributing information on organ donation. Conesa et al. (2004b) concluded that the largest impact in this regard was generated by television, followed by radio, printed magazines, and oral presentations. The most positive impact on personal opinion was found among individuals who received information at specialized meetings. Positive attitudes toward living donation are very strongly related to cadaveric donations (Conesa et al., 2004a; Chakraborty et al., 2010). Therefore, educating the public about the importance of whole body donation not only by television media or press but also by personal interaction with potential donors and their families by the members of anatomy departments needs to be taken into consideration.
As reported previously, many factors influence people's opinions toward body donations (Golchet et al., 2000; Conesa et al., 2004a, b; Ajita and Singh, 2007). These include age, religion, culture, personality characteristics, level of education, views on death and mortality, body image, previous experience of donation, and humanitarian concerns (Golchet et al., 2000; Conesa et al., 2004a, b). In Nigeria, religious, socioeconomic, and cultural factors may likewise hinder willing donors from signing up for bequest programs. Certain Nigerian religions demand immediate burial of bodies following death, and adherents of such teachings may not bequest their bodies to anatomy departments for dissection. Nigeria is a mixed society where different tribes have different cultures. In some cases, there are rites associated with the burial of diseased family members, and observance of such rites may generate opposition by family members against the bequest of bodies of potential donors (Izunya et al., 2010).
Many similar obstacles once existed in other countries which later developed successful body donation programs, such as in Korea (Park et al., 2011), Israel (Notzer et al., 2006), and Thailand (Nayak, 2004; Wilkelmann and Güldner, 2004). However, the initial negative reactions of the public were eventually overcome by an extensive education campaign that emphasized the social benefits of body and organ donation. Meanwhile, despite the above potential threats to the establishment of body bequest programs in Nigeria, the challenges are not insurmountable. A similar situation with regard to body shortages faced Tzu Chi College of Medicine in Taiwan, where the majority of the population holds the belief that deceased persons' bodies should not be disturbed after death (Lin et al., 2009). The college implemented a gross anatomy dissection course using only voluntary, nonanonymous donors, emphasizing humanitarian aspects of the body gift within the Taiwanese social and cultural setting. Cadavers were regarded by students as “great body teachers” or “silent virtuous teachers” (Lin et al., 2009) and appropriate religious ceremonies were held with invited family members. This unique course curriculum has inspired many individuals in the community to bequeath their bodies, and cadaver donation has consequently increased.
With focused educational media campaigns, redesigned anatomy curricula that connect potential donors to medical students, and legislative support, individuals in the community will certainly consider bequeathing their bodies to medical education.
One important benefit of an increased supply of bodies for departments of anatomy (by body bequest programs) is in the training of better-qualified doctors and healthcare providers. As a result, community health services will improve significantly. In return, anatomy departments and medical colleges can reciprocate by organizing some medical support for families of donors similar to those implemented in China (Zhang et al., 2008). Moreover, donors must be assured of respectful and ethical use of their gifts in the anatomy laboratory, as well as benefiting from ritual ceremonies and appropriate burial of the remains. Such remains should be buried in accordance with the religious inclinations of the donors (Nayak, 2004; Wilkelmann and Güldner, 2004; Lin at al., 2009; Park et al., 2011) and the family members should be familiarized with the burial sites, thereby enabling them to pay respect to their departed members. Besides, it is also recommended that anatomy departments and medical colleges organize an annual convocation of thanks, where donors are publicly acknowledged and appreciated for their postmortem contributions to medical education (Elansary et al., 2009; Lin et al., 2009; Pawlina et al., 2011). In South Korea, for example, after the dissection of bequeathed bodies, funeral services are organized by medical schools to publicly honor the donors (Park et al., 2011). Such practices are proven to increase public awareness about body bequests, as well as encourage body donation from the surrounding community. In such an educational environment, medical students learn to handle and treat donated bodies with the utmost respect. In addition, they also gain experience in nurturing the doctor–patient relationship by meeting the donor's families (Lin et al., 2009). In the Netherlands, an altar was erected by the anatomy department of Radboud University Nijmegen Medical Centre to honor body donors, and donors' families and friends were invited to unveil the monument erected in honor of their loved ones (Kooloos et al., 2010). Because of the rich media coverage of this public event, the surrounding community was better sensitized and informed about body bequest programs, as well as about the benefits of such a gesture to society.
It is therefore the responsibility of all departments of anatomy in Nigerian medical schools to work with the newly established Anatomical Council of Nigeria, the Medical and Dental Council of Nigeria, the Anatomical Society of Nigeria, as well as the Ministry of Health to solve the issue of cadaver shortages. It is recommended that a Ministerial Panel be appointed to facilitate the implementation of the above recommendations in support of a formal body bequest program in Nigeria, as this would substantially increase the supply of cadavers for anatomical teaching and research. Perhaps this may be one of the first tasks of the newly appointed Anatomical Council of Nigeria to establish a formal body bequest program. The time to begin this process is now.
NOTES ON CONTRIBUTOR
OLUWOLE BUSAYO AKINOLA, Ph.D., is a lecturer I in the Department of Anatomy at the University of Ilorin, Ilorin, Nigeria. He teaches anatomy to second- and third-year medical and biomedical students.