Cultural practices of the Zulu ethnic group on the body and their influence on body donation

Influence of religio-cultural beliefs on whole-body donation: A quantitative analysis of a predominantly South African Pedi Community

BACKGROUND

Body donation is a predominant mode of body sourcing in many countries including South Africa; however, it continues to be limited among the different ethnic groups in the Black African population of South Africa which have been observed to be largely unwilling to provide consent to donate their bodies. Religious and cultural beliefs have been suggested to influence willingness to donate one's body to science, with most religions regarded as accepting of body donation globally. In contrast, cultural beliefs and practices in the African continent impede body donation. Therefore, it is crucial to understand the factors that influence willingness to participate in body donation among the various ethnic groups of the Black African population of South Africa, particularly the Pedi ethnic group.

PURPOSE

This study sought to investigate factors that determine the disposition to participate in body donation and the influence of religious and cultural beliefs on willingness to consent to donate one's body among a predominantly Pedi community of the Black African population of South Africa in the Limpopo province.

METHODS

In this cross-sectional study, 300 four-page questionnaires were distributed to conveniently sampled individuals from the GaMaphale (Pipa) village of the Limpopo province of South Africa. Descriptive statistics (frequency tables and Pearson's chi-square test for independence) followed by a stepwise backward regression were conducted to obtain key factors determining willingness to donate one's body, the influence of religious and cultural beliefs, and also the likelihood of willingness to participate in body donation in this community. A p-value of < 0.05 was considered statistically significant.

RESULTS

A total of 190 (63 %) responses were obtained. The level of awareness about body donation was 30 % (n= 57/190), and 41 % (n= 78/190) of respondents were willing to donate their bodies. Age (p = 0.001), educational level (p = 0.037), belief in a higher entity (p = 0.007), ancestral (p < 0.001), and religious (p < 0.001) beliefs allowing for body donation were statistically associated with willingness to donate one's body. The elderly respondents were less likely to agree to donate their bodies compared to younger adults. Respondents who understood that religion allowed them to self-donate were 50 times more likely to agree to donate their bodies than those who did not.

DISCUSSION AND CONCLUSION

Findings reflect that a high percentage of respondents were unaware of body donation while a considerable number of respondents were willing to donate their bodies to science based on their religious and cultural beliefs allowing them to do so. Potential body donors from this community will likely be younger and belong to religions that allow body donation. The need to increase awareness about body donation programs through awareness campaigns, especially among religious organizations that may allow for body donation, is warranted in this community. This work was supported by the National Research Foundation (TTK220214660416).

Support for whole-body donation among educational staff in Southwestern Ugandan medical educational schools

BACKGROUND

The teaching of anatomy from early days of medical education relied on the use of cadaver; hence, the present study assessed the support for whole-body donation among academic staff.

METHODS

This is a cross-sectional study conducted from January to March 2024 in Southwestern Ugandan medical educational schools among 160 academic staff. Ethical approval was obtained and structured questionnaires were distributed to study participants in the selected Medical Educational Schools.

RESULTS

Among the 160 sampled academic staff, only 16 % and 18 % supported the donation of their whole-body and the bodies of their relatives/friends for anatomical education respectively. The reason put forward for respondents support for whole-body donation were contribution to medical science (88.5 %) and learnt from someone's body (53.8 %). The fear of misuse of their body (42.5 %), cultural (53.7 %) and religious (44.8 %) belief were the reasons for non-support for whole-body donation among the study participants.

CONCLUSION

This study concluded that support for whole-body donation among academic staff was low; reasons for non-support were fear of misuse of body, religious and cultural beliefs; hence, we recommend the need for massive desensitization of the public aimed at building confidence on whole-body donation in the community.

A consolidated summary of South African human skeletal repositories

AIM

Human skeletal repositories are crucial resources for research and education in human biology, variation, anatomy, biocultural frameworks, forensic/medico-legal casework, heritage and understanding the past. In this review paper, we assess the composition of human skeletal repositories in South Africa, along with the ethical and legal frameworks that safeguard their curation.

METHODS

The data and information pertaining to local human skeletal repositories were gathered through a combination of literature review and direct contact with local curators for information. Data pertaining to source origins, sample demographics, and temporal distribution (where applicable) were extracted and reporting trends across publications were assessed.

RESULTS

South Africa has 12 main human skeletal repositories, six affiliated with universities and six with museums. There are over 12 300 human skeletal remains housed across these repositories, mainly of cadaveric, archaeological, forensic (medico-legal), and unknown origin. Universities are primarily stewards of large cadaveric collections (n = ± 6 200); however, a few manage archaeological (n = ± 1 300) and forensic repositories (n = ± 1 000). Museums exclusively curate repositories of archaeological origin and approximately ± 3 700 archaeological individuals can be found countrywide.

CONCLUSIONS

The ethical challenges faced by South African repositories are deeply connected to the country's colonial and apartheid history. Concerns related to consent, autonomy, cultural sensitivity, data availability and the respectful treatment of the deceased, require constant attention and consideration. We highlight several initiatives undertaken to address these issues, including the implementation of new management approaches by repositories, a shift away from using unclaimed bodies, efforts in deaccessioning and repatriation and an increased focus on community engagement.

A South African case study on anatomical embalming for human body donation programmes with toxicological considerations

Body embalming, a practice with deep historical roots across various cultures, forms the backbone of contemporary human body donation educational programmes. In this study, we explored current embalming practices within six South African human anatomical dissection programmes, focusing on the use and volumes of key chemicals-formalin, phenol, and alcohol-and their associated health risks and potential toxicity. We measured and compared aspects of embalming practices such as the duration of body preservation and the annual intake of bodies. Variations in embalming practices and chemical ratios across different South African universities were found. However, the consistent use of formalin, phenol and alcohol were observed across all six programmes. Formaldehyde concentrations used in South African dissection programmes were within the generally acceptable international range. Regarding arterial embalming, South African dissection programmes showed widespread adherence to international embalming practices, with one programme using a substantially lower concentration of formalin. The dual nature of formaldehyde as both an effective preservative and a recognised carcinogen was underscored in relation to human health regarding chemical toxicity. Phenol, like formaldehyde, was consistently used as it is important for the inhibition of bacterial and fungal growth. Alcohol was also consistently used, but there was much greater variation in its volume across South African institutions. Our data showed a slight positive relationship between storage duration and the volumes of formalin and phenol in human embalming fluid. South African regulators enforce stricter exposure limits than those set by the World Health Organisation and various European agencies. While South African institutions operate within internationally acceptable ranges of chemical use that both maximise preservation and minimise toxicity, we acknowledge that these data are preliminary. Further investigation is encouraged to ensure embalming practices effectively protect all those involved and support the educational goals of human anatomical dissection programmes in South Africa.

Anatomical human body donation in South Africa: Inconsistencies of informed consent

INTRODUCTION

Informed consent is critical for maintaining the ethical standards associated with the utilization of human donor bodies by tertiary education institutions. Body donation programs undertake the responsibility for procuring human donor bodies for didactic and research purposes. However, its processes require scrutiny regarding best practice guidelines and the South African National Health Act (SA-NHA) (2013). Moreover, acknowledging and addressing the current perceptions of human body donation are indispensable in bridging the gap between academia and society. This study aimed to compare informed consent documentation and procedures across South African tertiary education institutions and their affiliated human body donation programs (HBDP) in accordance with international guidelines. The findings were used to create a human body donation form template aligned to current international best practices for consideration by the South African HBDP.

METHODOLOGY

A review of information and consent forms collected from South Africa's eight HBDP was conducted. The analyses consisted of a broad evaluation of information provided, ranging from the terms-of-use for human donor bodies to the commitments made by HBDP to body-donors. The results were considered in conjunction with the International Federation of Associations of Anatomists and other recent publications on informed consent in HBDP.

RESULTS

Only two of the eight HBDP provided information and consent forms in more than one language. Most allowed donors to select how their bodies will be utilized - education, training and/or research. Some (6/8) made provisions for the next-of-kin to receive the cremains. Only one tertiary educational institution mentioned the occurrence of a memorial service in its documentation. An HBDF template was created aligned to current international best practices for presentation and possible adaption by SA HBDP.

DISCUSSION & CONCLUSIONS

Human body donation forms (HBDF) requires thorough examination for the promotion and sustainability of HBDP. Effective communication by employing standardized non-technical terminology conveyed in language that is understandable and native to potential donors facilitates the deliverance of informed consent. Inconsistencies regarding the use and management of bodies catalyze the weakening perception of human body donation. Thus, this process of securing informed consent for body donation should be conducted in conjunction with public awareness campaigns and underpinned by the necessary policy and legislative reform.

Giving a voice to our silent teachers: Whole body donation from the donor perspective at one donation program in the United States

Human body donors play a crucial role in anatomical education, research, and clinical skills training, and those interested in anatomical donation may bequeath their bodies to body donation programs (BDPs). The purpose of this study was to evaluate the perspective of body donors on the donation process in order to make recommendations for improvement that align with donor values. A survey was administered via email to 2145 individuals that had enrolled in The Ohio State University's BDP and yielded a 40% response rate. Results showed that a majority of registered donors do not place high importance on detailed consent options during the enrollment process, but do value BDP oversight, such as through the use of an oversight committee to supervise the program. Only 9.1% of donors felt that their loved ones should be permitted to make changes to their consent forms after they have passed. Although 96.2% of participants would allow photos/videos to be taken of their donated bodies, females were significantly less likely to consent to this than males (p = 0.001), as well as less likely to allow their donations to be utilized for anatomy outreach (p = 0.023). Racial minorities were significantly less trusting of the university to treat their donation with dignity and respect compared to White registrants (p = 0.034). Suggestions for improving BDP protocols include the implementation of an annual newsletter for registrants, improving methods to spread awareness about donation, increasing transparency during the consent process, and creating resources for donors' families.

Leading the transition to ethical human body sourcing in Africa: The South African experience

BACKGROUND

The use of human bodies for anatomy education and research forms an integral part of the training of health professionals around the world. However, the ethical acquisition of human remains for this purpose has been a challenge in many countries, particularly for those on the African continent. South African institutions have however, been able to progressively transition to a more ethical approach to human body acquisition. The aim of the current study was to investigate the provenance of human bodies and the number used in South African health sciences institutions during the period 2017-2021.

METHODS

an online self-administered anonymised questionnaire was circulated to all health sciences institutions in South Africa. Questions were focused on establishing the provenance and the associated number of bodies and body donor programmes.

RESULTS

responses were received from thirteen of the fourteen South African institutions. All thirteen institutions use human bodies for teaching and research, with the majority of the institutions being reliant on bequests (77%) and family donations (62%), and less on unclaimed remains (46%). Most institutions have established body donor programmes. Four institutions were negatively affected by the effects of the pandemic. Memorial services, which continued during the pandemic, were conducted by eight of the thirteen institutions.

CONCLUSION

South Africa is leading the transition to the ethical acquisition of human remains on the African continent. It is hoped that South African institutions will soon transform to the exclusive sourcing of bodies through willed donation and provide guidance and support for the other countries on the continent.

Commemoration of body donors in a religiously diverse society: A tale of two Korean medical schools

Although a diversity of religions exists in South Korea, with Buddhism and Christianity (Protestantism and Catholicism) being the two main faiths, Korean beliefs are deeply rooted in Confucianism. Despite the notion that the Confucian norm of filial piety discourages body donation to medical science, there has been a mindset shift in favor of body donation, driven by a heightened awareness of the body bequest programs and the care and dignity accorded to the altruistic body donors, together with the institution of commemorative services to honor them. As spirituality and religion are known to be factors that influence body donation, how religious- and non-religious-based memorial services are held to honor the donors as exemplified by two Korean medical schools-from a public university with no religious affiliation and from a Protestant-based university-are described here. The key concept of expressing gratitude and respect for the donors and their family members has positively impacted body bequest programs in this multi-religious society. Commemorative services held to pay tribute to the altruistic body donors may play an important role in inspiring a humanistic spirit in students, regardless of religious or non-religious beliefs, as exemplified by the two Korean medical schools. The takeaway here is that the elevation of spirituality in memorial services effectively resonates with society, thereby demonstrating the impact of spiritual principles independent of religious influence.

Do religious and cultural considerations militate against body donation? An overview and a Christian perspective

The development of anatomy as a scientific undertaking appears to have left little room for religious and cultural input into the conduct of anatomical investigations. This has been brought to the fore by questionnaires regarding the willingness or otherwise of individuals to donate their bodies for dissection, with higher levels of willingness from those without religious affiliations. This has led to the assumption that there is inherent opposition to body donation by those with a religious stance, although there has been little exploration of this. This is increasingly important with growing awareness that anatomy is an international discipline, leading to increasing attention to the religious and cultural contexts within which it is practiced. There is a diversity of responses toward body donation within different countries, as well as by those influenced by Islam, Hinduism, and Buddhism. Additionally, there are diverse cultural attitudes within Confucianism in Asia, Zulu in Africa, and Māori in New Zealand. Even those within the Christian church are influenced by a variety of values, some of which are in tension, with emphasis on the sacredness of life and the significance of burial being negative toward body donation, with informed consent and altruism pointing in a positive direction. The challenge for anatomists is to understand those within their communities, seek to appreciate their perspectives, and also make known the potential of body donation and dissection for enhancing medical practice and improving the education of future health workers.

Whole body donation for teaching in Ghana: The perspectives of medical doctors

Historically, both donated bodies and unclaimed bodies have been the sources of human bodies for anatomy dissection globally with the latter discouraged for ethical reasons. Ghana lacks well-established body-donation programs, thus relying heavily on unclaimed bodies. Medical doctors benefit foremost from human bodies in their training and therefore should have a better disposition toward body bequeathal. This study assessed the perception, knowledge, and attitude of medical doctors in a Ghanaian institution toward body donation. As the first Ghanaian study on the subject, it provides the foundation for systematic study of the subject in Ghana. An internet-based questionnaire was administered to volunteering medical doctors requesting information on their perception of, knowledge of, and attitude toward whole-body donation. Data were summarized as frequencies. The 200 respondents comprised 1 consultant, 4 specialists, 14 residents, 63 medical officers, and 118 house officers. About 194 (97.0%) were familiar with body donation while 6 (3.0%) were not. Also, 39 (19.5%) were willing to donate their bodies, 98 (49.0%) were unwilling, and 63 (31.5%) undecided. Religion, culture, mishandling of bodies, and lack of awareness were barriers to body donation. Finally, 178 (89.0%) viewed human body dissection as relevant and should remain as part of medical curriculum. Doctors were aware of body donation though only few were willing to donate. Cultural and religious factors were major hindrances to body donation for anatomy education and research, though they were willing to persuade others to participate. Deliberate public education on the subject is required to grow body donation in Ghana.

Acquisition of cadavers for anatomy education and research in Malawi

BACKGROUND

The use of human cadaveric dissection forms an essential part of teaching anatomy to health sciences students in Malawi. Despite worldwide struggles in acquiring sufficient human cadavers for anatomy education, the current recommendations on the best anatomy practices require the use of cadavers exclusively from the body donation programs. The current study aims to describe the sources of cadaveric bodies used for anatomy education in the Malawian context and reflect on the feasibility of using cadavers from the body donation program only.

METHODS

A retrospective audit of the cadaveric records for the 2006-2022 academic years at the Kamuzu University of Health Sciences was done. The perceived challenges when sourcing the cadavers were identified and described based on the authors experiences in Malawi.

RESULTS

The majority (97.3%) of the cadavers used between 2006 and 2022 were unclaimed bodies. The mean age of the cadavers was 45 years. Most (95.6%) of the unclaimed bodies were males. All the unclaimed bodies were sourced from hospitals. The body donation program in Malawi was patronized by populations of European descent only. Strongly held sociocultural and religious beliefs as well as economic reasons were perceived as significant barriers to acquiring cadavers of the indigenous Malawians through the body donation program.

CONCLUSION

Cadavers for anatomy education in Malawi are mainly from unclaimed bodies, similar to other African countries. The authors support the transition from using "mostly unclaimed bodies (and, less often, body donation)" to using "mostly body donation (and, less often, unclaimed bodies)" through awareness campaigns that are targeted to address the prevailing challenges.

Investigating the status of whole-body donation across the United States of America

Dissection of human body donors is a valuable part of anatomical education, research, and clinical training. In the United States, deceased human bodies are predominantly sourced through whole-body donation programs (BDPs) housed by academic institutions. Due to the lack of information regarding BDPs, the aim of this study was to gather information from US BDPs through a survey to better understand the donation process and standard operating procedures of these programs. In 2021, a Qualtrics survey was distributed to 125 BDPs and yielded responses from 72 program leaders. Collectively, these programs received more than 26,000 whole-body donations annually. Findings show that 70% typically receive enough donations to fit the needs of their institutions, 17% receive a surplus of donations, and 13% receive too few donations. Sixty-eight percent of programs permit next of kin body donation regularly or in times of need, and 44% allow next of kin to make changes to a donor's donation form after death. On average, over 85% of the registered donor population is composed of white individuals, and only 6 institutions have methods in place to promote diversity among their donor population. Overall, there is considerable variability in the operation of BDPs across the United States. These findings can be used to make recommendations about donor enrollment and program operations to ultimately improve the donation process. Future research needs to investigate the opinions and preferences of body donors along with their next of kin on the body donation process and associated policies.

Challenges to sourcing human bodies for teaching and research in Africa: Are the challenges insurmountable?

The teaching and learning of human anatomy by dissection has existed for thousands of years. Over the centuries, evolving ethical considerations for the sourcing of human bodies for dissection have resulted in a transition from the use of unconsented individuals to that of body donors and the institution of body donation programmes around the world. However, major challenges on the African continent have resulted in the continued use of unconsented or unclaimed bodies and the ethical dilemma for African anatomy departments regarding their use. Some of the key difficulties in sourcing donor bodies which exist on the African continent emanate from religious, cultural, societal trust and other confounding factors. This manuscript explores the challenges and suggests ways in which some of these constraints may be overcome.

The relationship between body donation and attitudes toward death and altruism in Changsha City in China

In recent years, China has been facing a shortage of cadavers for teaching medical students. A better comprehension of the attitudes and factors influencing the general public's opinion toward body donation would be invaluable for planning and implementing body donation programs. Although altruistic attitude and attitudes toward death have received considerable attention in recent years globally, they have been largely understudied in China. Herein, the potential relationship between attitudes toward altruism and death, and willingness toward whole-body donation in a sample of university students in Changsha City in China were analyzed. A multi-stage sampling method was adopted to recruit 478 Chinese college students from two universities: the Medical College of Hunan Normal University (n = 272) and the College of Civil engineering of Hunan University (n = 206). The study participants were assessed by a sociodemographic questionnaire, the Death Attitude Profile-Revised (DAP-R-C) questionnaire, and the altruism scale. Moreover, Chinese University students demonstrated moderate willingness to donate their bodies. The mean score of the willingness of study participants to donate their bodies was 3.138 ± 0.933 (5-point Likert scale). Acceptance toward death, gender, and type of university were positive factors, whereas fear of death negatively affected willingness toward body donation. Regression analysis showed that factors, including gender (β = 0.237), type of university (β = 0.193), natural acceptance (β = 0.177), and fear of death (β = -0.160) influenced willingness toward body donation. Overall, the present study provides hitherto undocumented evidence on factors influencing willingness toward body donation among Chinese university students, which can assist in designing public awareness programs for encouraging body donation.

The Practice of Teaching and Scientific Research on Cadaveric Material Remains Crucial for Medical Education

The practice of teaching and scientific research on cadaveric material remains crucial for medical education, especially in surgical disciplines. However, in Italy, this practice has been neglected due to legislative insufficiency and financial constraints. Although innovative methods and tools like simulators and e-learning have been adopted, direct hands-on experience with human cadavers remains irreplaceable for medical and surgical education. The absence of clear legislation governing cadaveric dissection has limited availability for teaching and research, resulting in economic burdens for universities and individuals seeking proper surgical training. To address this issue, Law No. 10/2020 and the recent implementing decree were introduced in Italy, providing detailed legislation on the donation of bodies for educational and research purposes. The law emphasizes the importance of respecting the donor's specific choices and aligns with constitutional principles promoting culture, research, and health protection. However, some critical issues related to consent procedures, duration of body availability, and preservation of anatomical parts remain. Additionally, the law's dissemination among the population needs improvement. Future optimization could include allowing donors to choose the timing of body donation and considering different timeframes for body availability. Furthermore, the implementation of consent procedures could be simplified to increase donations. The law should also address the need for appropriate reception centers and allocate resources for effective dissemination. Despite these challenges, Law No. 10/2020 represents a significant step forward in enhancing medical-surgical training, scientific research, and the overall quality of patient care in Italy.

Anatomy: An Opportunity for South African Health Science Students to Discuss Their Emotional Responses to Human Remains in the Laboratory

Human dissection remains a cornerstone of the anatomy learning experience. However, the emotional response of students to the use of human remains for learning is influenced by a number of factors and is not always positive. Therefore, this study explored the students’ emotional response to and factors affecting their perceptions of the use of human remains for learning anatomy in a South African context. Four hundred and eighty of the 1538 health sciences students enrolled in human anatomy courses at the University of the Witwatersrand, South Africa during 2016 and 2017, completed a voluntary survey. The survey included closed and open-ended questions on students’ emotional responses, coping mechanisms and the factors that affected their perceptions of the use of human remains and dissection. Overall, the students had a positive emotional response. Their perceptions of dissection were affected in positive and negative ways by their religious and cultural beliefs. Feelings of gratitude and respect toward the cadaver were informed by belief systems. However, anxiety was caused by the delay of accepted sociocultural burial practices. Peer discussions were the preferred coping method, which may provide an approach for students to discuss how their beliefs influence their dissection experience.

The Italian law on body donation: A position paper of the Italian College of Anatomists

In Italy, recent legislation (Law No. 10/2020) has tuned regulations concerning the donation of one's postmortem body and tissues for study, training, and scientific research purposes. This study discusses several specific issues to optimise the applicability and effectiveness of such an important, novel regulatory setting. Critical issues arise concerning the learners, the type of training and teaching activities that can be planned, the position of academic anatomy institutes, the role of family members in the donation process, the time frame of the donation process, the eligibility of partial donation, or the simultaneous donation of organs and tissues to patients awaiting transplantation. In particular, a universal time limit for donations (i.e., one year) makes it impossible to plan the long-term use of specific body parts, which could be effectively preserved for the advanced teaching and training of medical students and surgeons. The abovementioned conditions lead to the limited use of corpses, thus resulting in the inefficiency of the whole system of body donation. Overall, the donors' scope for the donation of their body could be best honoured by a more flexible and tuneable approach that can be used on a case-by-case basis. Furthermore, it is deemed necessary to closely monitor the events scheduled for corpses in public nonacademic institutions or private enterprises. This paper presents useful insights from Italian anatomists with the hope of providing inspiration for drafting the regulations. In conclusion, this paper focuses on the critical issues derived from the recently introduced Italian law on the donation and use of the body after death and provides suggestions to lawmakers for future implementations.

Body donation in Italy: Lights and shadows of law No. 10/2020

INTRODUCTION

Recently, law No. 10 of February 10, 2020, entitled "Rules regarding the disposition of one's body and post-mortem tissues for study, training, and scientific research purposes" was introduced in Italy. Although its provisions respond to a constructive subject, some practical issues are evident in the approved text.

MATERIALS AND METHODS

A systematic review of the literature was performed by searching online medical and juridical databases to identify publications and Italian law provisions related to body donation programs.

RESULTS

The updated regulatory framework was outlined and compared to that in force previously, and the following features are discussed: (a) matter of law; (b) donors' information and consent; (c) reference centers and funding, and (d) procedural regulatory details. Several critical issues were detected in the approved wording with respect to teaching/training recipients, the role of university anatomy institutes, family members' exclusion from participating in the donation process in any capacity, the duration of donation, the management of corpses, partial donations, and the compatibility with organ donation. Suggestions are provided to overcome certain operational limitations in implementing the regulation, which is still being drafted to date.

CONCLUSIONS

This article shares with the international scientific community the principles and controversies underlying a regulatory innovation introduced in Italy to allow legislative amendments to inadequate provisions of body donation, as well as draw the attention of the entire anatomic community to critical issues if other countries undertake the same legislative reform.