Supervisor: Presenter:

Prof. Md. Shafiqul Islam PhD Mohammad Azmain Iktidar, Sabrina Afroz
Adjunct Faculty, Dept. of Public Health, NSU. Student ID: 2035598680, 2035109680

Research with Autopsy

in Medical Science

Date: 9th April, 2021 | Clinical Epidemiology

Preamble

• Research with Autopsy is very common in Medical Science 1,2 . (Bharambe et al., 2019) (Romi et
al., 2019)
• In developed and many developing countries, there are specific acts, rules, and regulations for
donation, dissection, and research with dead body3. (Habicht et al., 2018)
• However, In Bangladesh, there are no guidelines for research and use of human cadavers for
teaching and research purposes in Anatomy4. (Nurunnabi et al., 2011)
Preamble

• From the British era, medico-legal autopsy is done by executive order. But there is no medico-
legal rule and regulation in Bangladesh. No consent is required to perform autopsy for medico-
legal purposes. Specimens can be collected from unclaimed dead bodies for research in forensic
and pathology with consent of authority but without the consent of the deceased/relative in
Bangladesh (Personal Communication with Forensic expert 2020).
• Head neck surgeons used to perform temporal bone dissection on dead bodies without guidelines 5.
• Therefore, Bangladesh Medical Research Council took the initiative to formulate the "Research
with Autopsy in Medical Science" guidelines. Under these guidelines, all biological sciences that
will deal with the human body or necropsy tissue can perform autopsy research as well as build up
an expert group of surgeons in Bangladesh.
Operational Definitions
Definition of Research

Research can be defined as the attempt to achieve new knowledges by finding the answers to clearly
defined questions with systematic and rigorous methods. The fundamental principles of the research
was issued in Belmont Report in 1978. These are :
• Respect for person
• Beneficence
• Non maleficence
• Justice
Definition of Donation

Donation is defined as a bequest of body after death written during his or her lifetime for purpose of
teaching and research to medical school. (Riederer et al.,2014)
Definition of Unclaimed Body

The body of a deceased person who has no near relative or whose body has not been claimed by any
of his close relatives within after three days of death considered an unclaimed body.
Definition of Autopsy

An autopsy (post-mortem examination) is a surgical procedure that consists of a thorough

examination of a corpse by dissection to determine the cause, mode, and manner of death or to
evaluate any disease or injury that may be present for research or educational purposes 11,13,15. (Morar
et al., 2008, Human Tissue Act 2004, Irish et al., 2018)
Types of Autopsy

• Medico-legal/Forensic Autopsy: It is performed at the special request of the judiciary department

to establish the cause, manner and type of death, whether violent /nonviolent/homicide /suicide
/accident.
• Pathological Autopsy: It aims to establish a certain diagnosis regarding the cause of death and
death generating factors specific for certain diseases. Pathological autopsy leads to the
improvement of medical care by revealing errors of clinical diagnosis, ranging between 10% and
25%.
Types of Autopsy

• Anatomical Autopsy: It includes procedures where body is sectioned in order to emphasize and
study the topographical anatomy and the structure of its components as a part of the medical
education, training of physicians and scientific research.
• Virtual Autopsy: In 21th century, imaging techniques e.g., X Ray, CT Scan, MRI and other
methods became more and more sophisticated thus allowing non-intrusive human autopsies to be
performed.
History of Autopsy
Inception

• The term “Autopsy" derives from the Ancient Greek autopsia meaning ‘to see for oneself’
(Dehner et al., 2010).
• Around 3000 BCE, ancient Egyptians were one of the first civilizations to practice the removal
and examination of the internal organs of humans in the religious practice of mummification.
(Kelly et al., 2008)
• Later Sushruta in 7th or 6th century BCE and Romans in 150 BCE also performed dissection of
human body. Amongst the Arab physicians Avenzoar and Ibn al-Nafis were notable in this regard.
(Stephine et al., 2013 , Standring et al., 2016)
• In 44 BCE, Julius Caesar was the subject of an official autopsy after his murder by rival senators
to understand the cause of the death. The physician reported that the second stab wound of Caesar
was the fatal one
Institutionalization

• Forensic pathology in trial was given high importance in Roman Empire. Medical testimony was
required during a trial, such that the manner of death, whether it was infanticide, homicide,
abortion or poisoning
• Institutional form of forensic medicine book, the five-volume masterpiece titled ‘Xiyuanjilu’ is
found in China in 1247. It was written by Song Ci, who is now remembered as the father of
forensic medicine.
• In 1302, the first systematic medico legal autopsy was performed by Bartolommeo da Varignana in
Bologna, Italy. But the first written records concerning forensic pathology appeared in 1507, “The
Bamberg Code”.
• In 1539, an Italian judge granted physicians the right to dissect corpses of executed criminals.
(Standring et al., 2016)
Institutionalization

• In 1543, Andreas Vesalius conducted a public dissection on the body of a criminal. He articulated
the bones, this became the world's oldest surviving anatomical preparation (skeleton).
• He published his work on human anatomy entitled De Humani Corporis Fabrica Libri. Following
this publication medical schools began to dissect human cadavers. (Rokade et al.,2013)
• First modern autopsy was done by anatomist Giovanni Morgagni. He wrote a book named “The
Seats and Causes of Diseases Investigated by Anatomy” in 1769, earning him the title ‘Father of
Anatomical Pathology’. ( Dehner et al.,2010)
Current Trend

• Since 1955, in most western countries the number of autopsies performed in hospitals has been
decreasing every year. Only the medico legal autopsy is performed.
• In the UK in 2013 only 0.7% of inpatient adult deaths were followed by consented autopsy. In the
United States, autopsy rates fell to 7% in 200017. In the UK, following the Human Tissue Act
2004, all organs and tissue must be returned to the body unless permission is given by the family.
Anatomical Acts

• In 1832, British Parliament passed the Anatomy Act, allowing doctors, teachers of anatomy, and
medical students to dissect donated bodies. This Act also allowed physicians and surgeons legal
access to unclaimed bodies for dissection purposes and also established the concept of voluntary
body donation (Irish et al., 2008)
• This act was replaced by the Human tissue Act, 1961 and the revised Human tissue act of 2004.
(Standring et al., 2016)
• In India, the Anatomy Act was enacted in 1949 in Maharashtra state and was called as the Bombay
Act. This allowed donated and unclaimed body for the purpose of research and medical education
if there is no claim to one’s body within a 48-hour timeframe. (Bharambe et al., 2019)
Anatomical Acts

• Guidelines for Autopsy Pathology is found from Srilanka (CPSL National Guidelines).
• In 2012, The International Federation of Associations of Anatomists (IFAA) recommended that
donated bodies to be the gold standard of body acquisition. (Habicht et al., 2018)
• Bangladesh uses unclaimed body for teaching and research with ethical uncertainty and without
any act.
Religious perspective of
research with dead body
In Islam

• Quran says mutilation or disfiguration of the corpse, even the bodies of non-muslim enemies, is
forbidden as such procedures damage the integrity of the dead person's body.
• According to the Quran, like the soul, the body is a "gift" from Allah; therefore, a person has no
authority, ownership, or stewardship on his future dead body. Therefore, advance directive/will is
not considered an absolute right in Islamic law.
• Quran also says, “To save a life he saves all mankind" and “to save a life unlawful act is allowed
in case of necessity“. With this philosophy, Islam justifies organ donation and forensic autopsy 6.
(Aramesh et al., 2009)
• Moreover, a principle of Sharia Law, e.g., Ijtihād (independent legal and moral reasoning),
accommodates some advanced biomedical procedure7. (Ghaly et al., 2012)
In Islam

• "Ijtihād" and "necessity" justify the Islamic countries in dissection and research with the human
body for education and advancement of medical Science.
• In the late 90s Shiite school of thought allowed dissection of corpses in case of necessity of
educating life-saving medical knowledge and techniques in cases of unavailability of the corpse of
non-Muslims corps6. (Aramesh et al., 2009)
• In 2000, Sunni school of thought allowed organ donation, even donating to non-Muslims as well
in light of Islamic legal maxim "necessity" except the reproductive system, the brain's cells and the
nervous system7. (Ghaly et al., 2012)
• According to the European Council for Fatwa and Research, the advance directive will of the
deceased or (filling card) is analogous to the drafting of a testament according to Islamic law 7.
(Ghaly et al., 2012)
In Hinduism

• According to Hindu Puranas, Rishi Dadhichi donated his bones in a "Vajra" created by the Gods 9.
(Loukas et al., 2010)
• In ancient India, the human body was dissected by Sushruta in 500BC. They believed that to be a
good clinician; one must first be a good anatomist. Therefore, Hindu donate organs and dead
bodies for medical purposes9. (Loukas et al., 2010)
In Christianity

• Christianity religion has the same notion as Muslims as both rooted in the same Abrahamic
religion3. (Habicht et al., 2018)
• In 1231 Frederick II, the Holy Roman Emperor, issued a decree that trained doctors to hold a
human body dissection once every five years8. (Gholipour et al., 2019)
• But still, Christian's situation seems more heterogeneous3. (Habicht et al., 2018)
In Buddhism

• The Buddhist majority of countries rely exclusively on body donation. Buddhist ideology is to
save lives is truism. So they usually donate their bodies and organs for the advancement of
medical Science.
So religion, folk beliefs, culture, and local history strongly influence body
dissection. The ritual and spiritual importance of an "intact" body prevent
them from donating and dissecting body10. (Jones et al., 2012)
Importance of Respect in Research with Autopsy

• The human body maintains the identity with his/her body even in death. Also, a dead person's
body has an intrinsic ethical value that requires respect11. (Morar et al, 2008)
• Human cadavers are treated with respect to the way we treat the person alive. If the dead body is
treated as a simple carcass, a waste product would mean downgraded standards applied to the
person. Also, proper treatment applied to the cadaver has its roots in the moral-ethical imperative
to respect the family's mourning of their painful and irreversible loss11. (Morar et al, 2008)
• Moreover, we also respect the supreme sacrifice as they donate for teaching and research purposes
without usual funeral and religious services.
Importance of Consent in Research with Autopsy

• Consent of cadaver autopsy in anatomy, pathological and the forensic autopsy vary.
• In forensic, the principle of a person's autonomy has secondary importance due to this procedure's
legal compulsoriness. If the deceased wishes during their lifetime or a similar wish of the family
(through the mechanism of law) that his/her body will not be autopsied, the forensic autopsy is not
performed12. (MRC 2014)
• As autopsy and dissection procedures damage the integrity of the dead person's body, so moral-
deontological rule to take consent is imperative.
• The morality of procuring the unclaimed cadaver for dissection/ research violates a person's self-
determination principle. Unclaimed body is not altruistic; they may base on the material, the
extrinsic value of the human cadaver. So consent is of utmost importance for research on autopsy
is the reflection of respect13. (Human Tissue Act 2014)
Justice for Research with Autopsy

• In 2012, the International Federation of Associations of Anatomists (IFAA) rationalized that the
study and research with human bodies shall be on willed donated body only 3 to prevent
discriminating against, e.g., mental illness or poor, minority groups whose cadavers have
frequently been used by anatomical department10. (Jones et al, 2012)
• However, it is justified to include people with a mental health condition as they should not be
outside of healthcare research innovations. Therefore, it is important to give equal opportunity to
these patients in research.
• However, certain safeguards need to be in place to ensure these vulnerable groups 13. (Human
Tissue Act 2014)
• Research with dead bodies is also justified as certain diagnostic errors can also be avoided in the
future3. (Habicht et al., 2018)
Confidentiality in Research with Autopsy
on Donated Body

• Deontological Code of Medical ethics depicts the necessity of respecting the patient’s right to
confidentiality, an obligation even after death.
• The medical records regarding the autopsy are also subject to professional secret rules 11. (Morar et
al., 2008)
Trust in Research with Autopsy on Donated Body

• Throughout the research with the dead body, codes of research integrity should be maintained to
increase trust between the researchers and diseased families that may increase the donation pool.
Trust also ensures the rights, safety, dignity, and well-being of research participants 13. (Human
Tissue Act 2004)
Procurement of Dead Body
• Most of the countries (66%) procure a mix of unclaimed and donated bodies.
• Some countries use unclaimed bodies and imported bodies, e.g. Saudi Arabia, Turkey, Malaysia,
Micronesia and smaller sovereign states and European territories from the Caribbean.
• 32% of the countries exclusively use donated bodies, e.g. Czech Republic, Denmark, France etc.
• 31% countries exclusively use unclaimed e.g., Greece, Italy, Romania etc.
• Countries that mainly depend on body donation are Portugal, United States. South Africa, China.
• Countries that mainly depend on the unclaimed body are Mexico, Colombia, Uruguay, Ghana.
Kenya, Malawi, India, Indonesia, Iran and Bulgaria.
• Libya, Singapore use imported dead body.
• Fiji, Samoa, and the Solomon Islands do not use anatomical dissection at all.
 Guidelines for Research with Autopsy in Medical Science
This guidelines shall regulates the research activities with autopsy in Medical Science unless there is anything repugnant in
the subject or context.
Guidelines for Research with Autopsy in Medical Science

1. ​ esearch with autopsy shall be done in approved institution. Approved institution means a
R
public or private hospital, medical institution, university approved by the Government to carry
on anatomical, pathological and forensic examination and dissection.
2. ​Use of Human tissue in research with autopsy:
I. The removal and storage of human tissue from deceased patients.
II. Use of deceased tissue or organ.
III. Use of deceased whole dead body (cadaver).
IV. Use of bone/skeleton.
V. DNA /RNA research from cadaver/ viscera.
VI. Relevant material such as hair, nail, body fluid, blood, gametes (sperm/ova).
Guidelines for Research with Autopsy in Medical Science
3. Source of autopsy:
I. Donor
a) Registered before death: If any person expresses a request in writing through affidavit
during his/her lifetime that his/her body or any part of body be given to approved
institution for being used after his/her death for the purpose of medical education and
research.
b) Registered after death: If the deceased during his/her lifetime has expressed a verbal
request for his/her body or any part of the body to the family members/relatives/legal
guardian that be given to approved institution for being used after his/her death for the
purpose of medical education and research. In this case, Affidavit can be made by family
members/relatives/legal guardian after death of donor.
II. Operator Material (e.g., thyroid, vermiform appendix, umbilical cord, placenta, aborted
material etc.)
Guidelines for Research with Autopsy in Medical Science

III. Forensic material

IV. Archived Material: Material remaining in the museum of department.
V. Relevant material. Tooth, nail, hair, gamete, blood, bile, bone marrow, body fluid (Nasal
and Bronchial lavage), joint aspirates, pericardial, peritoneal, pleural fluid, saliva, pus,
stomach contents, breast milk and even a single cell that has come from a human body,
then the sample shall be classified as relevant material.
4. ​Researcher shall have a Research ID.
Guidelines for Research with Autopsy in Medical Science
5. Exclusion criteria: All donors are screened for infectious diseases like AIDS, Hepatitis B & C, active
tuberculosis, syphilis, and spore bearing organisms like Clostridium tetani etc. Donors who are known to
be infected with any of these diseases are refused for donation due to the risk to medical investigators and
procurement personnel. Unclaimed body shall be accompanied by a death certificate.
6. Consent: Appropriate consent shall be obtained for the removal, storage and use of body material
including DNA and RNA for research. Affidavit must state the declaration of donation with a
humanitarian, altruistic goal, without pursuing a material or another type of benefit for the purpose of
education and research.
a) To give consent, the individual shall understand the nature and purpose of work/research, risk and
disposal of body after research to able to make an informed decision. They shall also understand that
‘significant’ risks inherent in the way the sample will be obtained, such as processing of body, genetic
tests, media. The information must be in the form or leaflets or information sheets, along with the
consent form. Information shall be available in widely spoken languages. In case of electronic based
consent video, audio or braille etc. shall include.
Guidelines for Research with Autopsy in Medical Science

b) Individual can give broad consent in the will. Any kind of research or research with as
many as part of body can be done.
c) If a donor expresses for specific types of research, these must be respected. Donors shall be
provided information about how future research will be approved within the scope of the
consent they have given. A donation may not proceed if a donor places conditions on their
consent which cannot be met or guaranteed.
d) Surrogate consent shall be allowed. The parents, 1st line relative - wife, husband, brother,
sister, son, daughter, parents or close relative (in case of before mentioned relatives are
absent) shall provide surrogate consent.
e) For the removal, storage or use of the tissue of babies from stillbirths or neonatal deaths
surrogate consent shall be obtained from parent(s)/legal guardians.
Guidelines for Research with Autopsy in Medical Science

f) For the removal, storage or use of the tissue from lack of mental capacity person. Surrogate
consent shall be obtained from parent(s)/legal guardians However, certain safeguards need
to be in place to ensure vulnerable group when they do participate in research.
g) In case of forensic, archive and operating materials, generic consent shall be given by the
Head of Department to use of valuable store human tissue in future unknown research.
h) The minimum age of consent to donate one’s body is 18. Guardian’s consent shall be
obtain in case of donating one’s body below 18 and participant’s lack of mental capacity.
i) The consent cannot be retrospective.
Guidelines for Research with Autopsy in Medical Science

10. Withdrawal of Consent: Consent may be withdrawn at any time, whether it is specific or
generic.
11. B
​ efore the promulgation of the guidelines “Research with Autopsy in Medical Science”, all
unclaimed body/organs/tissue in the department shall be valid for research as archived
materials. Generic consent is accepted in these cases.
12. Waive of consent: Individual consent shall be waived in case of unclaimed body. Materials
older more than 30 year shall be waive of consent. Consent for 2 nd time shall be waived for
imported materials. In such case, written permission from Head of department / institute shall
be obtained.
Guidelines for Research with Autopsy in Medical Science

13. Import and Export: Export/Import human bodies, body parts and tissue and human material
shall be paid with dignity and respect according to culture and religion. Export/import human
material shall adequately explain the justification of the purpose. Export/ Import human
material do not need consent for the 2nd time. Documentation of source, consent and IRB,
quality of materials, timeliness of supply, risk of infection, quality of service, cost effectiveness,
or scientific or research need shall be present with Export/Imported human material. Such
documentation shall be submitted before the local IRB. Export/Import shall be retained by the
person undertaking, for at least five years. Disposal, if any specific by the deceased when
consent was obtained, such requests must be carried out. This may include, for example, the
return of material to the country of origin.
14. Ethical clearance: Research with Autopsy project shall be approved by Research Ethics
Committee. It may be Central (BMRC), Institutional (IRB) or Organizational (ERB).
Guidelines for Research with Autopsy in Medical Science
15. Preservation of material: Autopsy shall be preserved in the approved laboratory. Body tissue
material shall be well maintained by the researchers. Any putrefaction or catastrophe caused by
researcher shall be infringement of rule. Researcher shall be responsible for all consequences and
shall bear the cost if any.
16. Confidentiality: Donors confidentiality shall be strictly maintained even after death. Thus, all
findings of an autopsy shall be anonymous. No name and image of the donor shall not be
photographed or revealed.
17. Custodianship: Department of authorized institution shall be the custodian of material of Human
body tissue.
18. Time for procession: The researchers shall get a maximum period 7 years of time to act on. A
research material shall be retained in researcher’s possession as maximum as five years after
completion of research. Then it shall be disposed. In case of loan material, material shall be back to
department.
Guidelines for Research with Autopsy in Medical Science
19. ​Disposal: All the research material shall be disposed by the authority maximum 3 years after
research. Used tissue shall be bagged separately from clinical waste. It is not necessary for each
tissue sample to be bagged and disposed of individually. The date, reason for disposal and the
method used shall be documented. If not mentioned in the Will how to dispose the body/tissue,
dispose off by proper methods of disposal as per institute/ hospital practice.
20. ​Head of Research Institutions shall take responsibility to oversee whether the protection and
regulation has been of maintain in the use, storage/safe keeping, preservation, security of
biological material and disposal.
21. A
​ uthorization of such research can be done on the basis of Government act, or in it’s absence,
by interim BMRC guideline.
22. A
​ ny research with autopsy for genetics, transplantation, xenotransplantation etc. shall follow
the guidelines of that section.
Guidelines for Research with Autopsy in Medical Science

23. Infringement of rule: All shall abide by above mentioned rules during research with autopsy.
Anyone holding ‘bodily material’ without the qualifying consent of the person’s concerned,
extending processing time, intending to analyze the DNA or other research outside of the
protocol and use the results: these offence attracts a fine, a term of imprisonment of up to three
years, or both.
24. Reviews of Guidelines: The Guidelines shall be reviewed by the selected body on a 5 yearly
basis.
Anatomy in Modern Era

• A new thought process came into being that human dissection had no scientific utility in
Anatomy11. (Morar et al., 2008)
• Models, Ultra-sound, CT scan, X ray and currently, computer programs (ADAM - Animated
Dissection of Anatomy for Medicine) and three-dimensional computerized data bases are replacing
the use of cadavers in anatomy teaching.
• U.S. medical schools are now offering their anatomy curriculum without any cadavers as it costs
several million dollars to build a cadaver laboratory, requires a lot of space, safety measures, as
well as legal regulations. ( Gholipour et al., 2019)
Anatomy in Modern Era

• Preparation, maintenance and disposal of cadaver also costs money.

• Due to shortage of donations, relying on unclaimed bodies is also an ethical concern.
• It takes a long time to dissect cadavers and some body parts are so inaccessible that they may be
destroyed in the process.
• Textures and colors of an embalmed cadaver's organs do not match those of a living body and
donated bodies tend to be old and diseased.
Anatomy in Modern Era

• However, other school of thought says that alternative methods cannot replace the cadaver
dissection as the best method for anatomy teaching26. (Rokade et al., 2013)
• Cadaver less anatomy education has its drawbacks. It may be hard to develop a perception in
depth in a virtual body, and students will miss out on seeing bodies' natural anatomical
variations27. (Ghosh et al., 2015)
• Students may also lose the emotional, even philosophical impact of working with a cadaver,
commonly seen as a doctor's first patient.
References
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J. Anat. 23(6): 469-477
2. Romi,M.,M., Arfian, N.,  Sari ,D.,C.,R. 2019. Is Cadaver Still Needed In Medical Education?The
Indonesian Journal of Medical Education, 8: 3:
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History of Medicine 2:4 p1-4
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transnational Islamic bioethics. Med Health Care and Philos, 15:207–220
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Human Body for Teaching and Scientific Purposes. Romanian Journal of Bioethics, 6:4: 75-83
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(Accessed 3 May 2020)
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DA, Jonathan DM, Christine G. The Johns Hopkinss University press. Baltimore and London, 2003
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act/75/enacted/en/print  (Accessed 2 Jul. 2020).
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Louis, school of medicine. Scientific report.Washinton
18. Kelly, R., 2008. The Autopsy Through History. In Ayn Embar-seddon, Allan D. Pass (ed.). Forensic
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Schafer, Elizabeth D. (2008). "Ancient science and forensics". In Ayn Embar-seddon, Allan D. Pass (ed.).
Forensic Science. Salem Press. p. 43.
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Orientalia 2007;101.
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(Accessed  7 May 2020).
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22. Elezabeth
Thank You!