The dignity of the human corpse in forensic medicine.

Working with the dead is a very specific kind of work. Although a dignified handling of the corpses is demanded by the legislator and by the general public, neither the legal status of the corpse is undisputed nor is it obvious what a dignified handling of the deceased should consist of. In our hypothesis generating pilot study, we asked which concrete considerations are involved in daily practice of forensic specialists. We used an online questionnaire (invitations via e-mail) consisting of questions with single choice, multiple choice, and free text entries. The answers to single or multiple choice questions were displayed in pivot tables. The data was thus summarized, viewed, descriptively analyzed, and displayed together with the free text answers. 84.54% of the physicians and 100% of the autopsy assistants stated that considerations concerning the dignity of the deceased should play a role in daily autopsy practice. 45.87% stated that the conditions surrounding the autopsy need improvement to be ethically suitable. The analysis of the survey's results was based on Robert Audi's ethics, according to which three aspects need to be lightened in order to evaluate the conduct of a person morally: the actions, the motivation, and the way in which the actions are carried out. This systematization helps to identify the need for improvement and to make the vague demands for a dignified handling of corpses more concrete.

Conceptual frameworks for understanding the acceptability and feasibility of the minimally invasive autopsy to determine cause of death: Findings from the CADMIA Study in western Kenya.

Establishing the cause of death (CoD) is critical to better understanding health and prioritizing health investments, however the use of full post-mortem examination is rare in most low and middle-income counties for multiple reasons. The use of minimally invasive autopsy (MIA) approaches, such as needle biopsies, presents an alternate means to assess CoD. In order to understand the feasibility and acceptability of MIA among communities in western Kenya, we conducted focus groups and in-depth interviews with next-of-kin of recently deceased persons, community leaders and health care workers in Siaya and Kisumu counties. Results suggest two conceptual framework can be drawn, one with facilitating factors for acceptance of MIA due to the ability to satisfy immediate needs related to interest in learning CoD or protecting social status and honoring the deceased), and one framework covering barriers to acceptance of MIA, for reasons relating to the failure to serve an existing need, and/or the exacerbation of an already difficult time.

For Victims of Fatal Child Abuse, Who Has the Right to Consent to Organ Donation?

In rare circumstances, children who have suffered traumatic brain injury from child abuse are declared dead by neurologic criteria and are eligible to donate organs. When the parents are the suspected abusers, there can be confusion about who has the legal right to authorize organ donation. Furthermore, organ donation may interfere with the collection of forensic evidence that is necessary to evaluate the abuse. Under those circumstances, particularly in the context of a child homicide investigation, the goals of organ donation and collection and preservation of critical forensic evidence may seem mutually exclusive. In this Ethics Rounds, we discuss such a case and suggest ways to resolve the apparent conflicts between the desire to procure organs for donation and the need to thoroughly evaluate the evidence of abuse.

Medical Assistance in Death as a Unique Opportunity to Advance Human Immunodeficiency Virus Cure Research.

The inability to sample deep-tissue reservoirs in individuals living with human immunodeficiency virus (HIV) has greatly hindered accurate estimates of viral reservoir size and distribution. Animal models and collection of tissues during autopsies of HIV-positive individuals are 2 proposed solutions to this problem. Each, however, has its limitations. In this Viewpoint, we argue that tissue donation following medical assistance in death (MAiD) will form an invaluable resource for the characterization of the viral reservoir in the context of current HIV cure research. In support, we discuss a recent instance in which an individual living with HIV chose to donate their body/tissues to HIV research prior to undergoing MAiD at our institution. Going forward, we hope this will help provide support to individuals in their decisions around tissue donation following MAiD, while highlighting how healthcare providers, by complying with such wishes, can affect patient satisfaction in the last days of life.

Ethical considerations for HIV cure-related research at the end of life.

BACKGROUND: The U.S. National Institute of Allergies and Infectious Diseases (NIAID) and the National Institute of Mental Health (NIMH) have a new research priority: inclusion of terminally ill persons living with HIV (PLWHIV) in HIV cure-related research. For example, the Last Gift is a clinical research study at the University of California San Diego (UCSD) for PLWHIV who have a terminal illness, with a prognosis of less than 6 months. DISCUSSION: As end-of-life (EOL) HIV cure research is relatively new, the scientific community has a timely opportunity to examine the related ethical challenges. Following an extensive review of the EOL and HIV cure research ethics literature, combined with deliberation from various stakeholders (biomedical researchers, PLWHIV, bioethicists, and socio-behavioral scientists) and our experience with the Last Gift study to date, we outline considerations to ensure that such research with terminally ill PLWHIV remains ethical, focusing on five topics: 1) protecting autonomy through informed consent, 2) avoiding exploitation and fostering altruism, 3) maintaining a favorable benefits/risks balance, 4) safeguarding against vulnerability through patient-participant centeredness, and 5) ensuring the acceptance of next-of-kin/loved ones and community stakeholders. CONCLUSION: EOL HIV cure-related research can be performed ethically and effectively by anticipating key issues that may arise. While not unique to the fields of EOL or HIV cure-related research, the considerations highlighted can help us support a new research approach. We must honor the lives of PLWHIV whose involvement in research can provide the knowledge needed to achieve the dream of making HIV infection curable.

[Validation of medical ethical decisions at the bedside by the autopsy : Experience of the ethics committee at the Stuttgart Clinic]. / Validierung medizinethischer Entscheidung am Krankenbett durch die Obduktion : Erfahrung des Ethikkomitees am Klinikum Stuttgart.

BACKGROUND: Ethics consultations in a clinical setting can be challenging, specifically with respect to limiting therapeutic interventions in terminally ill patients. Some decisions will even be controversial. OBJECTIVE: Can a clinical autopsy be used to confirm the recommendations given by the ethics committee, i. e. limitation of therapy to palliative care? MATERIAL AND METHODS: We report an exemplary case of a patient with endocarditis and subsequent septic cerebral infarction. During treatment in the intensive care unit (ICU) two ethics consultations were held. Both times the patient' s clinical condition and prognosis were controversially discussed. The patient died after a recommendation had been given for supportive care. The subsequent autopsy, which is described in detail, confirmed a fatal set of symptoms with extensive destruction of the heart and disseminated brain infarcts. CONCLUSION: Clinical autopsies are crucial for an objective description of diseases and can corroborate the decision to limit therapeutic intervention in end of life care. It is a valuable tool in evaluating the quality of decision making in ethics counseling.

[Clinical autopsies from a medical ethics perspective]. / Klinische Obduktionen aus medizinethischer Sicht.

BACKGROUND: Autopsy quotas in Germany are persistently low. By way of providing an explanation, the (ethical) reservations of the general population against autopsies are presented. OBJECTIVE: Normative assessment of clinical autopsies, elaboration of ethically relevant arguments for and against autopsies and review of the suspected reservations of the general population. MATERIAL AND METHODS: Reanalysis of the literature, review of qualitative and quantitative studies on the subject field and discussion of the verified ethical argumentation figures. RESULTS: Historical prejudices (e.g. recruitment practice, popular belief and religious reservations) have long been inhibiting the acceptance of clinical autopsies. The current discussion on clinical autopsy is often focused on normative arguments and while autopsy critics primarily argue from an individual ethical perspective, autopsy advocates primarily argue from a social ethics viewpoint. Quantitative studies, however, prove that the majority of the population today has no (ethical) reservations against autopsies. CONCLUSION: Although most reasons for the persistently low autopsy rate are primarily structural and motivational, some normative implications relating to these aspects remain.

Consented Autopsy and the Middle-East.

Consented autopsy is almost non-existent in the Middle-East where established social and cultural beliefs regarding the procedure might discourage family members from requesting a consented autopsy. Evidence suggests that new information is obtained from consented autopsies. It would not be in the best interest of medicine if social and cultural misconceptions succeed in erasing the existence of consented autopsies entirely.

Is Consent to Autopsy Necessary? Cartesian Dualism in Medicine and Its Limitations.

When a hospitalization ends in death, a request for an autopsy can lead to an emotionally charged encounter between a physician and the deceased patient's family. A case is presented in which a cardiac surgeon, believing he might have made a mistake, requests an autopsy, but members of the deceased patient's family believe that she would not have wanted an autopsy performed. A central question discussed in this commentary is whether and when consent for autopsy is necessary. We discuss two theoretical frameworks that support differing views on this question. Beyond engaging this philosophical discussion, we also highlight a practical approach to discussing an autopsy with a grieving family by using the case presented.

The Penetrating Gaze and the Decline of the Autopsy.

Understanding the decline in the autopsy rate can be furthered through analysis of Foucault's idea of the medical gaze and the ancient Greek idea of theoria. The medical gaze has shifted over time from the surface of the body to the inner organs to the cellular and subcellular levels. Physicians and loved ones of the deceased person are not likely to "gaze" at the same levels. Patients' loved ones might not theorize as physicians do; they have different interests, which suggest the need for more attention to informed consent for autopsies. Responding to this need should take priority over efforts to increase the autopsy rate, and it can also be seen as an opportunity to improve autopsy and autopsy consent practices.

"Whenever they cry, I cry with them": Reciprocal relationships and the role of ethics in a verbal autopsy study in Papua New Guinea.

Verbal autopsy (VA) methods usually involve an interview with a recently bereaved individual to ascertain the most probable cause of death when a person dies outside of a hospital and/or did not receive a reliable death certificate. A number of concerns have arisen around the ethical and social implications of the use of these methods. In this paper we examine these concerns, looking specifically at the cultural factors surrounding death and mourning in Papua New Guinea, and the potential for VA interviews to cause emotional distress in both the bereaved respondent and the VA fieldworker. Thirty one semi-structured interviews with VA respondents, the VA team and community relations officers as well as observations in the field and team discussions were conducted between June 2013 and August 2014. While our findings reveal that VA participants were often moved to cry and feel sad, they also expressed a number of ways they benefited from the process, and indeed welcomed longer transactions with the VA interviewers. Significantly, this paper highlights the ways in which VA interviewers, who have hitherto been largely neglected in the literature, navigate transactions with the participants and make everyday decisions about their relationships with them in order to ensure that they and VA interviews are accepted by the community. The role of the VA fieldworker should be more carefully considered, as should the implications for training and institutional support that follow.

Ethical and Legal Challenges Associated with Public Molecular Autopsies.

There is a national movement supporting the retention and use of bio-specimens from deceased individuals for the purpose of genetic testing. This manuscript discusses the significance of postmortem genetic testing in the context of death determination by medical examiners (i.e., public molecular autopsies). We highlight distinctive concerns that are raised in the areas of consent, confidentiality, and return of results when genetic testing is performed as part of a public molecular autopsy. We believe our manuscript will contribute to the development of a robust ethical and legal framework for genetic testing in this context.

The social life of the dead: The role of post-mortem examinations in medical student socialisation.

Dissection has held a privileged position in medical education although the professional values it inculcates have been subject to intense debate. Claims vary from it generating a dehumanising level of emotional detachment, to promotion of rational and dispassionate decision-making, even to being a positive vehicle for ethical education. Social scientists have positioned dissection as a critical experience in the emotional socialisation of medical students. However, curricular revision has provoked debate about the style and quantity of anatomy teaching thus threatening this 'rite of passage' of medical students. Consequently, some UK medical schools do not employ dissection at all. In its place, observation of post-mortem examinations - a long established, if underutilised, practice - has re-emerged in an attempt to recoup aspects of anatomical knowledge that are arguably lost when dissection is omitted. Bodies for post-mortem examinations and bodies for dissection, however, have striking differences, meaning that post-mortem examinations and dissection cannot be considered comparable opportunities to learn anatomy. In this article, we explore the distinctions between dissection and post-mortem examinations. In particular, we focus on the absence of a discourse of consent, concerns about bodily integrity, how the body's shifting ontology, between object and person, disrupts students' attempts to distance themselves, and how the observation of post-mortem examinations features in the emotional socialisation of medical students.

Autopsy in Islam: Considerations for Deceased Muslims and Their Families Currently and in the Future.

Religious beliefs and cultures have influenced treatment of dead bodies in different ways by nations throughout history, and attitudes toward the deceased individuals have changed across time and so has the role and mechanism of autopsy. Islam has been a part of Europe for a long time; therefore, we would like to emphasize the important issues for Muslims and their families regarding death, autopsy, and funeral and to describe international perspectives of Muslim autopsies. Muslims have expressed their views on autopsy publically and internationally, and there have been claims of violation of the deceased, delays in burial, and nonconsideration of their religious beliefs. In this article, we aim to increase awareness and understanding of doctors about the religious and ethical issues important to Muslims and their families, so that appropriate considerations may be made where possible with regard to respectful treatment of deceased loved ones to decrease tensions presently being faced. Forensic medicine doctors could assist by undertaking autopsy without delay, in a private room by those of the same sex, and covering parts of the body not being worked on at that time.

Una reflexión práctica de autopsia clínica y percepción sociocultural en la Facultad de Medicina de Benguela, Angola / Reflections on the practice and sociocultural perception of clinical autopsy at the Medical School of Benguela, Angola

Introducción: la autopsia como práctica de la investigación médica, para diagnosticar causas de muerte, mostró relevancia a lo largo de la historia, mas hay tendencias a su reducción. Las causas son múltiples, la influencia de procesos y factores socioculturales pueden ser importantes en escenarios como África y Benguela (Angola). Hoy la ciencia muestra la estrecha relación entre salud, práctica médica y procesos culturales. Objetivo: valorar la percepción sociocultural que se tiene de la autopsia clínica tomando como base, estudiantes de medicina. Métodos: el estudio observacional, descriptivo y de carácter exploratorio, partió del análisis documental de la cultura e historia local. La observación de 5 procesos funerarios, para construir un cuestionario que se aplicó a 99 estudiantes de la Facultad de Medicina de Benguela, evaluando tres variables: procesos socioculturales que median la percepción social de la autopsia, factores socioculturales presentes en los estudiantes y criterios acerca de la autopsia. Resultados: las concepciones y percepciones socioculturales de la muerte en la etnia ovimbundo inhiben a la búsqueda científica de sus causas. Las observaciones en 5 procesos funerarios y la exploración mediante cuestionario en 99 estudiantes de medicina mostraron limitaciones y contradicciones en estos procesos con independencia de año cursado. Conclusiones: aunque la autopsia es un instrumento científico que verifica la calidad de los servicios médicos, en el contexto analizado, las percepciones socioculturales de la cultura ovimbundo limitan la visión científica, que origina contradicciones diversas. En la formación se deben realizar abordajes más profundos(AU)

Introduction: as a practice in medical research to diagnose causes of death, autopsy has shown to be relevant throughout history. However, it currently exhibits a declining tendency. The reasons for this are manifold, an outstanding role being played by sociocultural processes and factors in Africa and particularly in Benguela, Angola. Contemporary science shows the close relationship between health, medical practice and cultural processes. Objective: assess the sociocultural perception of clinical autopsy among medical students. Methods: an exploratory observational descriptive study was conducted based on document analysis of local culture and history. Observation of five funerary processes led to the development of a questionnaire which was applied to 99 students from Benguela Medical School. Three variables were evaluated: sociocultural processes mediating the social perception of autopsy, sociocultural factors among students and opinions about autopsy. Results: sociocultural conceptions and perceptions of death in the Ovimbundu ethnic group inhibit the scientific search for its causes. Observation of five funerary processes and exploration through a questionnaire applied to 99 medical students revealed limitations and contradictions in relation to these processes irrespective of the academic year being attended. Conclusions: autopsy is a scientific tool useful to verify the quality of health care services. However, in the context analyzed sociocultural perceptions by the Ovimbundu culture hamper its scientific approach, leading to a variety of contradictions. Training should include a more profound treatment of the topic(AU)