Book Review:

The Removal, Retention and Use of Human Organs and Tissue from Post Mortem Examination

Department of Health
The Stationery Office,
PO Box 29
Norwich
NR3 1GN
United Kingdom
16.95 or free on the web

This is an A4 sized paperback book issued by the UK government following a report resulting from the public unrest about compulsory post mortem dissections. This attracted interest from the news media following dissections of hospital patients and others during the past 50 years which culminated in large collections of organs found at Alder Hey Children's Hospital.

Overall I was favourably impressed with the layout of the book and opinions expressed therein. It seems expensive at five pence under 17 for a 48 page A4 paperback, but it was nicely produced and adding more verbosity would have helped no one. People are already over faced with information and what they are paying for is to get the facts as quickly and as easily as possible, and I feel confident that this is achieved by this volume.

The book is divided into sections, the first being an introductory chapter. This sets out the background to the current disquiet and provides facts and figures about it. On the basis that it would be very foolish and try and falsify any of the figures under such close media scrutiny, I would imagine that the information is as accurate as it can be. There are many quotes from relatives and parents of people who were dissected. These quotes were inserted into boxes with a light green background.

This includes details of present legal requirements and an admission that the medical authorities had been "paternalistic" and unsatisfactory in their handling of these matters. It also said that more informed consent had been required in some instances in more recent years. Also given were a number of web links:

The Interim report of the Bristol Royal Infirmary Inquiry http://www.bristol-inquiry.org.uk
The Report of the Royal Liverpool Children's NHS Trust (Alder Hey) inquiry
http://www.rlcinquiry.org.uk/index.htm
The Summit Meeting on Organ Retention
http://www.cmosummit.org.uk
Census dated 2000 of organs and tissues retained by NHS pathology services in England at the end of 1999
http://www.doh.gov.uk/organcensus
The 1999 report of the US National Bioethics Advisory Commission
http://bioethics.gov/pubs.html

Of particular interest is paragraph 14 of chapter 1 which says

14 The intention is to provide definitive advce which will enable a new beginning and start the process of restoring public confidence. While much of the public concern has been on the taking and retention of organs from post-mortems on children, the report and the recommendations address post mortem practice in all age gropups.

(emphasis by reviewer)

Chapter 2 gives concise details of the benefits to the community of post mortem dissections, including the storage of dissected organs for many years. These (para 8) include research into the human genome and investigations as to whether diseases such as Variant CJD existed, undiagnosed, in the past. However in para 4 it mentions that tissues can only be taken from a living person by consent, and indeed in some instances even that is legally hard to obtain (eg in children, or incapable adults). The implication clearly is the use of the word "living" - should this be extended to allowing people the freedom whether or not to donate their bodies when dead? Later there are hints that it might.

This is mentioned again in paragraph 11, and in 13 the current disregard for the feelings of relatives is again mentioned, and even a hint that some instances of dissection disregarded the law.

Paragraph 14 goes on to discuss the two different types of post mortem dissections, "hospital" and "coroner's". 33% of deaths are reported to coroners, and 62% of these result in a dissection. That is to say 20% of deaths result in dissections. But only 12% result in a court enquiry known as an "inquest". A box on page 9 gave some interesting information about coroner's dissections. The relatives have no choice, but they have the right for a representative to be present (eg a general practitioner) and it is not necessary for anything to be done more than is necessary to establish the cause of death.

This is of particular interest to cryonicists. If an experienced doctor is present and can help determine the cause of death with limited molestation of the physical structure of the body, then cryopreservation could be facilitated.

Hospital dissections require consent of the relatives. (para 19) Presumably if the deceased objected, he could arrange for his personal representatives to enforce this.

On page 10 it mentions that the Human Tissue Act 1961 says that for removal of parts for medical purposes in hospital dissections the wishes of the deceased also have to be considered. This completely demolishes arguments that have been made on the Internet by some people that " in law dead bodies are not people and can have no rights." It may be so elsewhere, but not under British law, apparently. British law isn't completely consistent, of course, as it limits such rights in some instances. But it does look as though changes may be made for the better. Paragraph 23 also uses the term "rights of the dead". It also says "... requires NHS trusts ... ensure the disposal is in accordance with wishes expressed by the deceased prior to death or by relatives." Of course arrangements for cryopreservation are "disposal arrangements" according to law. Dissection and delay are definitely not helpful to a successful cryopreservation.

Stillborn children are covered next - this subject undoubtedly is of concern to the public. Whole body donations for various purposes follow. Again the matter of consent, informed consent and under what circumstances dead people can give consent is discussed. Part 2 ends with the matter of disposal of parts retained for whatever purpose.

Chapter 3 is a discussion of issues and concerns over past and present practise of post mortem dissections. It noted that public disquiet with dissections had caused hospital staff to be less ready to ask for permission in more recent years, and there has been a decline in the number of hospital dissections since 1970. Paragraphs 10 and 16 discussed the instance of misinformed consent that had been obtained, and hinted that deliberately misleading statements were made.

Paragraph 19a referred to the problems of a "lack of objection" method of consent (ie "opt-out"). Paragraph 19b comments that people are not aware of their rights and little effort is made to explain them. Paragraphs 19d through 19g catalogued failures with retention of organs, record keeping, disposal, bereavement counselling, and respect for religion and culture. All of this was well summarised in a concluding paragraph 20.

Chapter 4 is entitled related issues and starts off with the Coroner's System. In paragraph 1 it sweeps aside any chance of informed consent for the dissection of someone who may have had a suspicious death with a "it is clear why ...". I cannot agree with this. It is just as clear why it is not compulsory to join a neighbourhood watch, or have a burglar alarm or panic button in your house. It should be a matter of personal and informed choice. It went on in paragraph 2 to list as a concern the previously mentioned fact that a coroner's dissection is limited to finding the cause of death. I see this limitation in existing law as something positive, not a defect. It also hinted in paragraph 3 that some people managed to avoid having organs of the deceased cut out for examination, and suggested that was a defect. Again I would say that it was a positive and caring attitude, not a defect. In paragraph 4 it said that approximately 12 million pounds were taken from taxpayers in order to perform post mortem dissections per year, and 35m were paid each year by the public for certificates allowing them to destroy specific bodies by fire. I am not sure of the relevance of the latter - maybe that the system makes a "profit" of 23m? But paragraph 6 which suggested reviews of current procedure again brought up the subject of wanting informed consent, and liaison with the funeral profession, so maybe the burglar alarm analogy is not quite lost. Paragraph 8 suggested a medical examiners type of system and a fundamental re-evaluation of the approach to establishing the cause of death.

In a chapter on importing body parts, the subject of frozen body parts was mentioned. Paragraph 13 suggested that frozen body parts had the potential to transmit viral and other infections. I cannot see why this may be any more so than with unfrozen body parts, but this may eventually shed doubt on the international shipment of bodies for cryopreservation purposes if this idea spreads around the world's legislatures. However paragraph 15 did not suggest that a ban was being considered.

Commercial use of human tissue and tissue banks concluded the chapter.

Chapter 5 provides the conclusions and recommendations. In fact this appears to summarise again what has gone before, but paragraph 14 has some worthy guiding principles, based on respect and informed consent. It called for organs and tissues being given and gratitude expressed by the community, rather than their being taken. There are a number of recommendations. Most interesting are

6 A full revision of the law,
7 Formal control of the import and export of body parts,
14 There should be program of public education as to what happens in a post mortem process and possible benefits to science of dissection,
16 Procedures should be established after public consultation as to consent for research (legal research as well? - I doubt it at the moment.)
17 Research should be commissioned into less invasive forms of examination

The book ends with an "annex" of individuals and organisations who contributed.


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