INTRODUCTION

Despite recent reforms in medical education techniques, cadaveric dissection continues to remain the cornerstone of anatomy curriculum and body donation constitutes the sole source of human bodies for dissection in most parts of the world.^1,2 Efficiently conducted body donation programs enhance the value of human dissection by inducing moral transformation among medical students, thereby promoting the development of professional competence which is essential for a future physician.^3,4 Moreover professional psychological profile of a physician is not innate but gradually develops during the course of medical curriculum from individuals own experience or are transmitted from or observed in others. Hence dissection room experience contributes to student's attitude to a cadaver and later physician's approach to the patients.⁵ In fact medical schools across the globe are utilising body donation programs to cultivate humanistic qualities of respect, empathy and compassion among first-year medical students.^6,7 Researchers have noted that while dissecting on a donated cadaver, medical students develop emotional attachment with the same, which could possibly help them to comprehend the psychosocial factors contributing to a patient's illness and thus contribute towards the making of empathetic physicians of tomorrow.⁸

Most of the developed nations like the European countries and the United States of America have well established body bequest programs.⁹ In contrast there are countries like India where body donation is yet to emerge as a popular practice among the general population.¹⁰ Increase in demand for human cadavers used in anatomical education due to the rise in the number of medical schools in India has resulted in educators relying mostly on unclaimed bodies for anatomical studies.¹¹ This is an area of concern from the ethical point of view considering the dubious practices governing the procurement of these unclaimed bodies in most cases.¹² Research reports have attributed the lukewarm response towards voluntary body donation in India to low level of awareness among the general population and have suggested awareness campaigns for sensitizing the same.^13-15 But this appears to be a superficial overview of the situation and an in depth analysis is essential to identify the factors actually responsible for the emaciated state of body donation in the country. Such an analysis would be critical in designing effective strategies to counter the problem which in turn would be a significant step towards addressing ethical concerns regarding procurement of human cadavers for academic activities in India.

In the present study our aim was to unearth the factors prevalent in the Indian society that adversely affects the health of body bequest programs in the country through a study based on a questionnaire that included a representative sample of first year medical students who have completed one year of training in anatomy. The rationale behind selecting such a study population was their first-hand knowledge and baseline sensitization regarding the value of cadaver based teaching in medical education.

METHOD

The study was conducted at the Department of Anatomy, [Name of Institution], India. We requested all the first-year undergraduate medical students from 2015-16 academic session (batch strength is 100) to participate in this study. The study involved responding to a self-designed, both open and close ended questionnaire (Box 1), which was framed to explore perceptions of first-year medical students from 2015-16 batch towards voluntary body donation. A pilot study was conducted with the study questionnaire among the first-year students of the previous batch (2014-15) to test and validate the same. The students were made to understand that participation was voluntary and responses would remain anonymous. They were assured that absolute confidentiality would be maintained regarding their responses, the documents would be retrieved only for a short period of time and would be used only for research purpose. Written informed consent was obtained from all the participants and the objectives of the study were clearly explained to them to reduce the risk of participant bias. The study questionnaire were distributed among 100 first-year medical students in June' 2016, prior to their summative assessment and responded questionnaires were collected by hand.

RESULTS

Among 100 first year medical students to whom the study questionnaire was administered, 98 returned it after their response. Among the respondents, 61 (62.2%) were male and 37 (37.8%) were female. The median age of the respondents was 19 years (range 18-23 years) and they represented 6 states of India, namely West Bengal (72/ 73.5%), Bihar (8/ 8.2%), Uttar Pradesh (6/ 6.1%), Delhi (6/ 6.1°%), Rajasthan (4/ 4.1%) and Madhya Pradesh (2/ 2%).

Analysis of the baseline knowledge among the respondents revealed that 73 (74.5%) of them were aware of the inadequate supply of human bodies for dissection classes in Indian medical schools, however majority of them either didn't know (61/ 62.2%) or had the misconception that donated bodies were being used for dissection (17/ 17.4%) when in reality we were using unclaimed bodies procured from our hospital wards. An overwhelming number of respondents (88/ 89.8%) were familiar with body donation and most of them i.e. 33 (33/88; 37.5%) respondents identified daily newspaper as the medium from where they came to know about body donation (Figure 1). However majority of the respondents were unaware about the procedure of body donation as 85 (86.7%) didn't know about the authorities to approach and 66 (67.5%) had no knowledge about the documentation required for pledging bodies for donation (Table 1).

The data used in the figure is obtained from the response to question 7 of the study questionnaire (Please refer to Box 1). Only those participants who had given a positive response to question 6 (Please refer to Box 1) answered to this question (Please refer to Table 1).

Figure 1 Graphical representation of source of cognizance regarding body donation as detailed by the participants of the study 

The findings of the present study regarding the attitude towards body donation showed that 52% of the respondents were in favour of pledging their bodies for donation in future. Among those who were against the idea or were yet to decide on it, 59.6% opined that they could change their decision if their known ones from the society donate their bodies for medical education. Among the respondents, 67.4% admitted that they would encourage the individuals known to them to donate their bodies. Moreover, among those who were either averse to this idea or were not sure, 53.1 % opined that their decision could change if human cadavers are treated empathetically during dissection and 65.6% were of the same opinion if human bodies are subjected to cremation following dissection. 75% of the respondents confirmed that they would not be at ease to dissect the body of a person known to them (Table 2).

In relation to the practices among the respondents of the present study regarding body donation, it was observed that none of them have actually pledged their body for donation. It was noted that in 6.1% cases, a person known to the respondent have registered themselves for body donation. Among the respondents, 11.2% participated in awareness programs regarding body donation in the past, whereas 23.5% of them were willing to contribute actively towards such programs in the future (Table 3).

Various suggestions were documented by the respondents which according to them would enhance the voluntary body donation program in India (Figure 2). The most popular (42/98;42.9%) advice was to increase awareness among general population, followed by display of recognition for donors in anatomy department of respective medical schools which was suggested by 27 (27/98; 27.6%) respondents. 22 (22/98; 22.5%) respondents felt that measures should be taken to ensure that donated bodies are handled with respect, 17 (17/98; 17.4%) were in favour of holding memorial services for those who have donated their bodies and 14 (14/98; 14.3%) respondents opined that identification of interested donors would yield desired output in this regard (Figure 2).

The data used in the figure is obtained from the response to question 20 of the study questionnaire (Please refer to Box 1). As this was an open ended question, multiple responses were documented by each participant which is reflected in the percentages shown in the figure.

Figure 2 Graphical representation of measures to enhance voluntary body donation in India as suggested by majority of the participants of the study 

DISCUSSION

The merits of cadaveric dissection in medical education have been time tested and till date it constitutes an integral component of teaching/ learning gross anatomy.^16-18 In recent times educators have been promoting the use of multimedia simulation technologies in the anatomy classroom to counter the shortage of human cadavers. However research has found that success of simulation tools is dependent on associated factors like pedagogy, content and individual skills. Hence efficiency of multimedia simulation as compared to traditional dissection is yet to be established.¹⁹ However the issue of procurement of human cadavers for anatomy teaching has been surrounded by controversies throughout the history of human dissection.^20,21 Presently there is a uniform consensus that the emphasis should be on ethical procurement of human cadavers and body bequest programs are considered as the gold standard in this regard.²² Moreover dissection based teaching has evolved from being primarily considered as just another mode of delivering knowledge to being the ideal place to cultivate ethical values among future medical practitioners.^23,24 Accordingly ethical care for anatomical bodies and handling the same with respect and dignity has emerged as the focus area in gross anatomy education.^25-27 Ethical issues are till date an area of concern in developing countries like India where medical schools mostly rely on unclaimed cadavers for dissection as number of persons who chose to donate body is considerably low.²⁸ The present study was undertaken to identify the factors responsible for the paucity of donated bodies in India by reflecting on the perceptions of a cross-section of first year medical students.

A gross insufficiency of cadavers has been reported in most of the medical schools in India and in more than 50% of these medical schools, the available numbers of cadavers were less than half the actual requirement.²⁹ Due to a lack of donated bodies, most of these institutes rely on unclaimed bodies which are insufficient considering the number of medical students.¹¹ In the present study, we observed that majority (74.5%) of the first-year medical students knew about the scarcity in the supply of human cadavers in medical schools in India, however 79.6% students were not aware that actually we were dissecting unclaimed human bodies to teach them gross anatomy (Table 1). We noted that an overwhelming number (89.8%) of students were familiar with body donation (Table 1), which is close to the findings of recent studies which have reported such awareness among 95.83% and 92% medical professionals in India.^14,15 We further observed that 52% of the first-year medical students were willing to pledge their bodies for donation which is higher than the findings of Rokade and Gaikawad (44.9%) and significantly higher than those of Ballala et al. (22%), both of which were conducted among healthcare professionals.^14,15 Our observation was also significantly higher than what was noted among anatomists (23.9%) from Nigeria.¹ Moreover it was also observed in the present study, that the proportion of potential body donors among the first year medical students could substantially increase in future if they are motivated to do so by their near and dear ones in the society. This was also significantly different from the findings of Ballala et al., where 72% medical professionals confirmed that their decision of 'no body donation' would not change under any circumstances.¹⁴ The first-year medical students were motivated enough to spread the awareness in the society as 67.4% of them were in favour of encouraging the individuals known to them for pledging their bodies (Table 2) and this could be due to their young age group i.e. median age 19 years (range 18-23 years) and that majority (62.2%) of the respondents were male as has been observed by previous researchers.^15,30,31

Although high levels of knowledge and attitude regarding body donation were noted among the respondents, the findings in relation to practice were disappointing. We observed that none of the students have actually pledged their body for donation, which is significantly lower than previous reports.¹⁴ We further noted that the situation was no better in the society in general as merely 6.1% of the persons known to the respondents have pledged their bodies for donation. Possible reasons for low level of body donation in practice among the first year medical students and their known persons in the society could be poor knowledge about the overall process of body donation i.e. the authorities and the documentation (Table 1). The fear that the body may not be treated with respect and dignity is an important factor which prevents one from body donation.³² This holds true in the present study also as 53.1% respondents, who were averse / unsure of encouraging known persons to donate their bodies, admitted that they could change their decision in future if human cadavers are treated empathetically during dissection.

Another major obstacle towards body donation in India is the overindulgence towards spirituality and religious beliefs.^28,29 India is a Hindu dominated country and the Hindu religion believes in the theory of incarnation. It preaches that though body is mortal, the soul is immortal and it changes body in each birth.²⁹ This is corroborated by our findings as 65.6% of the respondents who were either not willing to or had not decided whether to encourage near & dear ones to pledge their bodies, opined that their decision could subject to change if human bodies are properly cremated following dissection. Another reason cited in literature towards 'no body donation' is the inability to accept the dissection of own body or body of a known person being dissected, which could be attributed to emotional factors influenced by age old tradition among Indians which prohibit the use of knife on dead corpse.^29,33 Similar observations were made in the present study as 75% of the respondents confirmed that they won't be comfortable in dissecting the body of a person known to them (Table 2).

We sought suggestions from the students regarding possible measures required to be adopted to enhance the voluntary body donation program in India (Figure 2) and the most popular suggestion was to increase awareness about the issue among the general population (42.9%), which is quite ironical as only 11.2% of the respondents of the present study admitted to have participated in such programs and only 23.5% of the respondents were willing to actively participate in such programs in future (Table 3). Awareness campaigns are indeed the need of the hour and they should involve all forms of media, particularly print media as newspaper was identified to have the most penetration regarding familiarization with body donation in the present study (Fig 1). Besides social media could also be involved as it has a considerable impact among the young population of a country.³⁴ Moreover these awareness campaigns should be co-ordinated with the religious authorities as suggested by Alashek et al. (2009).³¹ Persistent efforts needs to be undertaken in working out effective strategies by involving the social workers to sensitize the general population and promote voluntary body donation.³⁵ Individual concerns of prospective donors should be addressed and due assurance should be given regarding respectful treatment of donated bodies as suggested by 22.5% respondents (Figure 2). The ideal place to initiate such practice is the dissection lab and anatomists are required to show the way with regards to proper handling of cadavers.³⁶ Streamlining the donation process is another area of concern in this regard as was observed in the present study (Table 1). Absence of a uniform national legislation governing the process of body donation has not helped the cause of body bequest programs in India.^13,20 The practice of honouring the donor either by public display of recognition, which was suggested by 27.6% respondents or holding memorial services as suggested by 14.3% respondents (Figure 2) could be fruitful in establishing body donation as a worthwhile option before the society as these strategies have been followed albeit successfully elsewhere in the world.³⁷ Last but not the least, as the medical schools would be the foremost beneficiary in the backdrop of a successful body donation program, hence they should act as nodal centres in respective pockets of the country and regulate as well as coordinate the body donation program to ensure its success.

CONCLUSIONS

Analysis of the results from the present study leads to the emergence of four factors which are possibly responsible for the poor health of body donation programs in India:

Based on the identification of the above factors we may suggest some possible measures to counter them and improve the present scenario in the country:

Finally we would like to emphasize on the importance of conducting surveys in line with the present study periodically and across medical schools of the country as the same would provide access to an extensive body of comparable data. Analysis of such multicentre data may provide valuable insights into the situation and could be useful in designing more precise strategies to make voluntary body donation popular in India. A streamlined and robust body donation program is essential for the future of medical education in India and convergence of efforts from all sections of the society is critical to the success of body donation in the country.

AUTHOR CONTRIBUTIONS

• SKG and SC designed and coordinated the research and the implementation and evaluation of assessment tools drafting, discussion and conclusions. SKG and SC conducted the review of written, statistical, methodological analysis and analysis of results.