Cadaver Donations Fall During COVID: Will Future MDs Suffer?

Alicia Ault

April 14, 2021

The COVID-19 pandemic has created shortages in many areas, including some less obvious. It has also interrupted the supply of human cadavers for medical education and research.

Some medical and allied health professional schools stopped accepting body donations to protect staff, students, and faculty from a pathogen that presented too many unknowns.

What impact will this have on the future of cadaver donations — when medical schools are already using other methods for teaching anatomy to medical students?

Each medical school donation program has its own rules about what bodies it will accept, with many refusing decedents who are obese, victims of trauma, or had any infectious disease. 

When COVID-19 came along, many schools simply stopped accepting donations, including the University of Miami Miller School of Medicine and Columbia University in New York City, said Joy Balta, MD, director of anatomical services and the body donation program at The Ohio State University College of Medicine.

Ohio State stopped accepting bodies on March 23, 2020. The program began accepting donors again within a few weeks — but with new protocols. All donors are considered potential carriers and are quarantined until they test negative for COVID-19.

Midwestern University never stopped accepting donors and does not test bodies for COVID-19, said Heather F. Smith, PhD, director of the anatomical laboratories and a professor of anatomy at the school's Glendale, Arizona campus. But, she said, "we treat every case as if it could be positive."

That means staff dons extra personal protective equipment and everything is sanitized. The main threat is before embalming, and Midwestern does its own embalming, said Smith. "Studies show that after the embalming process there's not going to be any transmission between the donor — even if they're positive — and anyone else," she said. "There is also a minimum of 30 days, usually longer, between when we receive a donor and when they go into the lab classroom, so we feel confident that there is no virus remaining," Smith said.

The International Federation of Associations of Anatomists (IFAA) said in May 2020 that programs could safely work with donors who had COVID-19 but each program would have to decide how to proceed.

The Cleveland Clinic had a different challenge, as it does not embalm the bodies it uses. "Anybody's that had a suggestion of COVID or had COVID, we don't take the bodies," said Richard L. Drake, PhD, director of anatomy at the Cleveland Clinic Lerner College of Medicine, Ohio. The bodies are tested when they come in and then refrigerated. A positive is rejected.

As a result, the Clinic only accepted 90 bodies in 2020, Drake said.

The Clinic also shifted all its anatomy to virtual reality in the spring of 2020, but Drake said he "was not overly thrilled" with having to give up the cadaver as a teaching tool. By the fall, the Clinic had received permission to bring students back into classrooms. Now, 35 students gather around a prosection — a cadaver that is typically dissected by Drake.

While most institutions have adopted protocols that balance the need for donations with the risks during an ongoing pandemic, they still face the continuing challenge of convincing enough people to will their body to science. Some have even created in-house body donation programs to try to convince the public that they've evolved from an often-sordid history that encompasses grave-robbing, and use of unclaimed bodies, which is still permitted in many states.

Current statistics don't really exist on how many cadavers are required in the United States or globally each year to sustain research and education. A 2014 study estimated that 18,000 bodies are donated to science each year, and that demand outstrips supply.

There's also competition from a growing "body broker" industry — for-profit and nonprofit companies that sell whole cadavers and body parts to pharmaceutical and device makers and research institutions. Most medical schools distance themselves from the body brokers, which are loosely regulated and have been the subject of many unflattering media exposés.

The competition for cadavers has led many institutions to turn to virtual anatomy or other technology-driven ways of teaching anatomy or practicing diagnostic imaging or surgical skills.

But many anatomists say nothing can take the place of a real human body.

Balta told Medscape Medical News that while it may not be as critical to learn gross anatomy on a cadaver, it is more important when acquiring clinical or procedural skills, "where tactile skills need to be transferred to the operating room." He doesn't see virtual reality or other technologies ever replacing human body donors.

"This is your first patient," Balta said, repeating a maxim that students at all schools hear beginning with their first gross anatomy lesson.

Drake is not in favor of going fully virtual. "My concern is that the medical students might not then see a cadaver — what the real anatomy looks like — until they walk in for their third-year surgery rotation," he told Medscape Medical News. "That's not a great time to see anatomy for the first time."

 "Although we're in the modern world, there is — not yet anyway — nothing quite yet like the experience of dissecting a human body," said Lisa Howley, PhD, senior director of strategic initiatives and partnerships in medical education at the Association of American Medical Colleges (AAMC).

"I think we're in a hybrid world right now," Howley told Medscape Medical News, noting that schools are using a mix of learning modes for anatomy.

In the AAMC's most recent survey, the nation's 155 accredited medical schools describe using a variety of approaches.

Of 143 programs teaching gross anatomy that answered the 2016-17 survey, almost all use virtual or online anatomical modules and cadaver dissection; a large majority use prosections (a cadaveric dissection by an instructor); a similar number use plastinated cadavers (in which bodily fluids are replaced with a hardened polymer), and about half used models or simulators. Fewer general surgery, surgical subspecialties, and obstetrics and gynecology programs used cadaveric dissection. Those programs make more use of models, simulators, and virtual or online programs.

The biggest growth in the past decade was in the use of plastinated specimens. Plastination permanently fixes the specimens and also allows for life-like coloration of the anatomy.

Getting Away From a Sordid History

In-house donation programs started growing in the 1980s. They have steadily gained steam, especially as more states ban the long-established and usually legal practice of using bodies unclaimed at hospitals and coroners' offices.

In the late 1880s US states began to pass laws that allowed unclaimed dead to be used for dissection — a response to the outcry over grave-robbing, which had been the primary means of acquiring specimens. Over the years, as more people could afford funerals and it became apparent that those of lesser means were often the ones who ended up as cadavers, states began reversing the unclaimed body statutes, according to a 2007 study.

But many states continue to allow bodies to be picked up by medical schools or mortuary schools if they aren't claimed within 48 hours.

It was not until 2016, for instance, that New York prohibited the use of unclaimed bodies. That came just after New York City's eight medical schools said they would no longer accept unclaimed bodies.

The IFAA recommended in 2012 that schools stop using bodies of executed prisoners or unclaimed bodies and instead primarily rely on donations. The United States still uses a mix of donations and unclaimed bodies.

The idea of body donation is still scary or distasteful to many Americans, in part because of scandals that have occurred. A 2017 Reuters series on body brokers showed how anyone could buy a body part for any purpose, that brokers sometimes manipulated decedents' families into donating, and that some companies had unsafe collection and storage practices.

Even so, public support of body donation may be growing, reflected in the increasing number of donations in many communities, says Balta.

Donation Programs Aim to Build Trust

New York state medical schools quickly pivoted after they stopped using unclaimed bodies. Eleven now have body donation programs, according to a list compiled by the University of Florida. School-sponsored programs are found in 47 other states, Washington, DC, and Puerto Rico. Delaware and Wyoming do not have medical schools but have cooperative programs with nearby out-of-state universities and anatomical boards that will retrieve bodies.

The Cleveland Clinic has the oldest donation program in the nation, established when the school began, in 1921, said Drake, but the program only brought in about 20 to 50 bodies a year.

The school now receives 200 or more donations a year, largely because of greater outreach, but also thanks to changes made to honor donors, said Drake.

When Drake arrived at the Clinic in 2003, he began an annual memorial service, in which students speak and talk with donor families. A faith representative usually also gives a speech, along with a resident and the Dean. Drake changed the burial site to Lakeview Cemetery, one of the city's most venerated burial grounds. Donors' cremated remains are placed in a mausoleum and they are listed as an individual burial, "just like the Rockefellers or anybody else who's buried there," said Drake.

Newer donation programs — such as one at Midwestern University, which began in 2016 — have focused on community outreach, said Heather F. Smith, PhD, director of the anatomical laboratories and a professor of anatomy at the school's Glendale, Arizona campus.

Midwestern, a private nonprofit medical school, was established in Downers Grove, Illinois, and opened the Glendale campus in the mid-1990s. The Glendale school's 5000 students — who are pursuing degrees in osteopathic medicine, dentistry, optometry, podiatry, physical therapy, and other health fields — essentially all take anatomy in some capacity, Smith told Medscape Medical News.

The school needs — and brings in — about 60 to 80 cadavers a year, said Smith. Usually people sign up for donation long before death, but sometimes the program serves those who do not know where else to turn. If someone chooses to donate, Midwestern will pick up the body free of charge (if the death is within a 30-mile radius), secure the death certificate, pay for cremation, and "return the cremains to the family if they request it," Smith said.  "I look at it as we're helping families that reach out to us in their time of need," she said.

More schools are raising their game when it comes to acknowledging donors, said Balta. At Ohio State, everyone is instructed to treat a body with respect, starting from when a body comes into the morgue. Donors are used to teach students ethics and professionalism. And the students are asked to be aware of the value of the donation. "Throughout the time that the donor is with us the students are expressing their gratitude through reflections that they write," said Balta.

A Future Without Cadavers?

The Cleveland Clinic is moving to a potentially cadaver-less future. Case Western Reserve School of Medicine and the Cleveland Clinic Lerner College of Medicine opened a 485,000-square-foot Health Education Campus, which devoted a space for a virtual reality-based anatomy lab.

Students are taught almost two dozen virtual reality modules. "We used those mixed in with the cadavers, with radiology, with ultrasound simulation — we're actually using everything," said Drake.

One of the nation's newest medical schools, the Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, California, has foregone use of fresh or lightly embalmed cadavers. Instead, the school is using a mix of virtual reality and plastinated specimens, said José Barral, MD, PhD, professor and chair of the Department of Biomedical Science at the school.

For students "to be able to understand the position and interrelationships of the different organs and systems within the human body — we can do that perfectly well with plastinated cadavers," Barral told Medscape Medical News.

At most schools, cadavers are generally only used for 2 years — and are destroyed as they are dissected. But plastinated specimens can last for years and are not destroyed during learning, Barral said. The students can also repeatedly return to the plastinated cadavers for education and practice.

By the time the first cohort of 50 students — who began in July 2020 — gets to surgical clerkships, "we may need to procure bodies," Barral said. But, he added, "that will be a much smaller operation and very very targeted," with for instance, an acquisition of an upper torso. But he does not envision having a full-fledged cadaver program.

Balta, however, believes that cadavers are still essential to turning students into physicians. Their journey begins with facing the body, and learning how to handle their feelings and process their emotions.

"None of this could happen if you're teaching them on a computer," he said.

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