Anat Cell Biol 2021; 54(4): 489-500
Published online December 31, 2021
Copyright © Korean Association of ANATOMISTS.
André Gustavo Fernandes de Oliveira1 , Augusto Ferreira Gonçalves1 , Júlia Nunes Soares1 , Letícia Henriques Neto Salgado1 , Bruno Silveira Santana1 , Matheus Venâncio Passos1 , Juliana Lopes de Oliveira Reis1 , Gustavo Candiá Arantes1 , Luís Filipe Sarmento Campos1 , Matheus Souza Carvalho1 , Lucas Cotrim Furtado da Gama1 , Alice Belleigoli Rezende1,2
1Department of Anatomy, Federal University of Juiz de Fora, Juiz de Fora, 2Department of Medical Education, Federal University of Juiz de Fora, Juiz de Fora, Brazil
Correspondence to:Alice Belleigoli Rezende
Department of Anatomy, Federal University of Juiz de Fora, Juiz de Fora 36036-900, Brazil
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Dissection and human specimens study remain the gold standard method for teaching anatomy. Due to the increasing health science courses in Brazil, the traditional way of obtaining bodies for scientific purposes, the unclaimed ones, became insufficient. In addition, this source is no longer ethically appropriate according to anatomists. In order to maintain the teaching quality, the Federal University of Juiz de Fora (UFJF) in Brazil, inspired by successful initiatives around the world, created a body donation program; Sempre Vivo. Besides the bureaucratic difficulty faced during its regulation, the implementation of a body donation program requires special attention regarding the religiosity, culture and uniqueness of the city's inhabitants. Informing people can demystify the process, avoid prejudice and increase the number of donors. In this way, an outreach project was designed to publicize Sempre Vivo and raise public awareness. In the first six years, Sempre Vivo reached the mark of 64 registered donors and seven bodies received. The donor’s profile corresponds to female (70.3%), 57 years of age, retired (50.8%), spiritist (53.1%) and with 12 years or more of formal education (90.6%). Considering that the UFJF has not received unclaimed bodies for ten years, the program was considered satisfactory up to this level and, in the future, it may be the exclusive source of anatomical specimens. The description of the creation and the publicizing of Sempre Vivo, the overcome challenges, as well as the donors’ profile, may encourage and facilitate the foundation of similar programs in Brazil and abroad.
Keywords: Body donation, Donors, Anatomy, Health education
Human anatomy is the science that studies the structures of the body in all its dimensions and complexities. Due to its relevance for the consolidation of knowledge in the Health sciences, anatomy has become indispensable to undergraduate courses [1-4]. Even with the advent of new methods of teaching in the 21st century, dissection and human specimens study remain the gold standard for the teaching of anatomy and it is established as a vital component to Health education, considering that it contributes significantly to the acquisition of essential clinical abilities and professional safety [5-8]. Dissabandara et al.  have reported that the majority of medical students have a positive perception of dissections. In addition, dissection may have an effect on course performance according to the student’s opinion . It is common knowledge among anatomy professors that the teaching of this science must rely on a prepared environment for students’ learning, as well as integral anatomical specimens, which should be well-preserved and in a sufficient quantity for the number of students, and they must also provide trustworthy knowledge [11-13]. Besides that, studying using human specimens, alongside ethical education, stimulates respect to the body and sensibility of future healthcare professionals, providing a genuine understanding of the concept of death [14-17].
In Brazil, the regulation for obtaining cadavers for teaching institutions according to the norms of the public authority came to existence in 1992, when a law came into effect supporting the usage of unclaimed bodies within a 30-day period, with the aim of teaching and scientific research . However, with the increasing number of medical schools and Health sciences courses, such a way became insufficient for maintaining an appropriate reserve of bodies at Universities, facing ever-increasing demands for bodies . Furthermore, the development of information technologies has allowed easier identification of bodies, therefore restricting the number of unclaimed bodies addressed to higher education institutions .
In addition, although in many countries, including Brazil, the use of unclaimed bodies remains legal, anatomists do not consider this way ethically appropriate to obtain bodies for teaching and research [19, 20]. The International Federation of Associations of Anatomists (IFAA) recommended in 2012 that only donated bodies should be used for this purpose . The use of unclaimed bodies and the bodies of executed persons was considered ethically controversial, since it uses bodies without consent. This practice was also criticized for discriminating against certain minority groups, such as criminals, poor, homeless people and individuals with mental illness [22, 23].
In this context, an alternative for the maintenance of an anatomical collection at Brazilian universities is to encourage voluntary donations of living donors, an already established strategy in other countries [19, 24-27]. The creation of programs with this aim answers to the request of individuals who intend to donate their own bodies to research and studies, providing a legal resource to fulfill this wish [28, 29]. Brazilian law supports the body donation to teaching and research, for scientific or selfless purposes, since 2002 [18, 30].
Body donation is accountable for the totality of bodies obtained in Canada, Chile, the United Kingdom, Japan, and New Zealand, whereas in the United States, Uruguay, Portugal, Korea, and South Africa most of the cadavers used in anatomy laboratories are from donation [23, 27, 31, 32]. In Brazil, there are successful programs in capital cities, such as at the University of São Paulo and at the Federal University of Health Sciences of Porto Alegre (UFCSPA); in the latter institution, the program has been running successfully since 2008 and it currently supplies all the demand in undergraduation [19, 24]. Organizations working with a private supplier of anatomical material, as described by Wingfield in the United States of America cannot operate in Brazil .
The success of the aforementioned initiatives inspired the creation of a similar program at the Federal University of Juiz de Fora (UFJF). However, the implementation of an innovative body donation program in a city demands special attention regarding culture and uniqueness of its inhabitants, whose profiles are different from the ones found in other countries and places, such as large urban centers. The aim of this paper is to report the experience of the creation of the Program of Voluntary Body Donation for Teaching and Research;
Juiz de Fora is a non-capital city with a current population of 516,247 according to the 2010 demographic census . The city has a 0.778 HDI (Human Development Index) and stands out in the educational sector. The UFJF and several private universities in Juiz de Fora make it a popular destination for students. UFJF held the 12th position among the Brazilian universities in the 2021 international ranking and some of its courses are considered among the best in Brazil .
In 2011, professors at the UFJF Department of Anatomy stated that the acquisition of unclaimed bodies for teaching and scientific research had become insufficient for the maintenance of the institution’s anatomical collection. There was a progressive decline in the acquisition of bodies connected to an increase in demands for anatomical specimens. In 2007, the Brazilian government allowed a larger number of spots and the creation of new Health courses at federal institutions, which significantly increased the number of students. In this context, it was imperative to find an alternative to keep human specimens available for the teaching of anatomy.
The voluntary body donation emerged as a possibility more suited to ethical principles and already been experienced by other universities [20, 36]. In this sense, a team was set up with professors and undergraduates from the Department of Anatomy, aiming to reach the theoretical frame required for the structure of a body donation program. Being so, the UFJF Department of Anatomy started organizing a body donation program
In 2012, the team started fulfilling the necessary steps for the institutionalization of the program. During this process,
In this context, the actions of the outreach project aim to maintain a permanent dialogue with the community to publicize the body donation as a real option, and of great importance for the qualified training of Health students. However, conflicts with faith and religious beliefs of individuals are always avoided. In addition, it is highlighted that the donation is a noble destination for the body, and also an altruistic attitude benefiting knowledge. Another objective is to make the academic and local community aware of the fact that body donation is the ethically correct option for maintaining the collection of the Universities , which need the participation of the population to preserve the quality of teaching. Currently, there are many legal questions about the use of unclaimed bodies [22, 39].
Since the beginning, the project included professors and undergraduates from the Department of Anatomy and a law professor as well as law students. All have contributed actively in all stages of planning and promotion. The first step of the awareness-raising strategy was the production of a logo associated with a slogan: “Give life to knowledge, donate your body to study” (Fig. 1). The
The second step in the awareness-raising strategy was the online publicization, by showing the program on the Department of Anatomy website (https://www.ufjf.br/anatomia/doacao-de-corpos-sempre-vivo/) aiming to reach the general population of Juiz de Fora and nearby regions. Regular meetings to discuss the awareness process resulted in the production of an information leaflet and banners to clear communication and publicize the program (Fig. 1). This represented the third step, highlighting important information about body donation, its benefits and how to get in touch with the Department of Anatomy. Parallel to raising the awareness of the general public, specific actions were also developed for the academic community and healthcare professionals, who are the direct beneficiaries of
It is important to note that the pupils’ participation alongside potential donors has positively impacted on the public awareness. On the other hand, the project has contributed to a broader and more qualified formation of the students involved by encouraging practical learning of teamwork, sharing responsibilities and developing ethical and communication skills.
As soon as the
When it is unfeasible for the donor to go to UFJF, these first contact or general instructions can be performed at home (in which case the team goes to the home of the donor), by telephone or email. After the conclusion of the process, the person receives the
If the donor decides to quit the program, he is instructed to get in touch with the Department of Anatomy in order to inform his decision, dismissing any other procedure or justification. After doing so, the registration is deleted from the database. In case the donor comes to pass away, the family is oriented about the posthumous ceremony, as well as about the necessary procedures for the final transportation of the body to UFJF, with the exception of violent death (such as homicide, suicide and traffic accidents with a victim). In these cases, even if all the documents and forms for donation have been filled and registered in life, the body must remain under custody of the State for analysis and cannot be forwarded to the University .
The payment for human material is not ethically acceptable and it is also forbidden by Brazilian laws, so there were no rewards or perks provided to the donors [21, 30]. Body donation is an altruistic gesture, with no direct compensatory benefit to donors, but of great value for education and research in Health sciences. The family that chooses to perform the posthumous ceremonies has to cover the expenses. However, the maintenance costs of the bequest program, preparation and final transportation of the bodies to the Department of Anatomy are supplied by the UFJF.
The program intends to honor the donors by attaching a plaque with their names on the wall of the entrance of the UFJF Department of Anatomy as a special donor memorial. Only donors who have previously agreed to it will have their names on the plaque.
After the arrival of the donated body, the professors of the Department of Anatomy will jointly decide about the use of each body: practical laboratory classes with tutorials for identifying structures using bodies (offered to nine undergraduate courses in Health sciences and Biology); dissection training courses and development of medical-scientific research.
The body bequest program
Some studies have highlighted the fact that the donor profile varies according to the application site [36, 42-44]. The donor profile, specific to each donation program, is important in order to direct strategies to publicize it to the target audience and, consequently, provide positive results.
The donors’ biopsychosocial data collected in the
The majority of registered donors are female (70.3%). The observed average age was 56.5±14.4 (SD) years. Among female, it was 53.9±14.2 (SD) years, with a minimum age of 19 years and maximum of 89 years. Among male, the average age was 62.7±13.1 years (SD), ranging from 33 to 91 years.
In relation to how the donors got to know about the
Most registered donors have an average formal education of 12 years or more, with only 9.4% having lesser education (Fig. 3B). Regarding the current job situation, 42.6% were active at the time of registration, 50.8% were retired, 3.3% were under government benefit and 3.3% under different circumstances. In this field, two registers did not contain information.
The information of the income was the following: 46.0% declared earning up to US $600.00 per month, including donors with floating income; 38.1% stated they earn between US $600.00 and US $2,000.00 a month, and 15.9%, more than US $2,000.00 monthly. In Brazil, the minimum wage in formal employment is R $1,045.00 (approximately US $200.00 a month).
Regarding religious beliefs and faith, more than half of the donors (53.1%) were Spiritist, 32.9% had other religious beliefs and 14.0% were self-proclaimed agnostic or atheists (Fig. 3C).
Considering the results of each year, there were no important changes in the donor profile since the creation of the program. However, in the first three years, in relation to how donors got to know the
The Department of Anatomy at UFJF attends nine undergraduate programs in the Health sciences and Biology, with a total of about two thousand students per year, which demands a high availability of bodies and anatomical specimens for study. Literature proofs that the contact with natural specimens and the dissection of bodies contributes heavily to the development of ethical and clinical skills which are essential for healthcare professionals, since this is, possibly, the first contact for most students with death [1, 2, 6, 7, 17]. This experience promotes reflection regarding death, selflessness, respect and generosity, contributing for the personal development of the students, as well as for a humanized professional formation [8, 11, 13, 14].
Traditionally, UFJF receives unclaimed bodies, and its availability has been decreasing progressively throughout the years. Considering that the last arrival of unclaimed bodies predates 2010, the alternative to preserve the supply of bodies was to create a program for voluntary body donation. In addition, with the publication of the IFAA guidelines in 2012, body donation has been highly encouraged, mainly for ethical reasons, and programs have emerged in many cities in different countries .
The relevance of donation programs to supply demands of bodies and anatomical specimens to teaching institutions in different countries and regions worldwide is widely evident and validates the current findings [13, 27, 44-46]. At the University of Otago, in New Zealand, the bequest program of the School of Medical Science has been active since 1943, with more than 140 annual registers in the last decades, and also with an approximate reception of 3,000 bodies . In Poland, the donation program at the University of Silesia, in Katowice, counts with approximately 1,250 registered donors since its creation, in 2003 . At the University of Bologna, in Italy, the authors observed an increase from 12 to 431 living donors between the creation of its bequest program in 2013 and the first trimester of 2020 . The number of body donations in Korea increased from 7 to 128 annually at the Yonsei University College of Medicine between 1992 and 2019, reaching a total of 2415 donors . In Brazil, the UFCSPA used to receive about 5 donors registers a year. After the creation of a body donation program, in 2008, this number increased to more than 29 annual registers . Table 2 summarizes the donation programs discussed and shows that the number of annual donor registers is higher in older bequest programs and in more populated regions. In Brazil, UFSCPA's body donation program has three times more annual donor registers than
On the other hand, unclaimed bodies are still widely used worldwide, including in Brazil. In some countries, it remains the exclusive source of bodies for teaching and research . Since this practice was considered ethically controversial, many anatomists find themselves in a complicated work situation. New discussions addressing this current condition need to occur in the international scientific community, considering the limitations of different realities [20, 41].
Regarding the profile of the donors registered on
The average age of registered donors is approximately 57 years old, which agrees with other studies that present similar results. Orsini et al.  found an average age of 59.1 years among registered donors in the University of Bologna, in Italy. In Ireland, the average age registered was around 60 years old; according to the authors, the use of the internet as a means of publicizing the body donation program resulted in a much higher number of younger donors . An important means of accessing
In addition, the fact that the main way to know
Regarding the level of study among donors, previous studies have shown that individuals associated with donation programs presented a level of formal education of approximately 12 years of study [36, 42, 44]. Most donors of
In addition, regarding the current job situation of registered donors, the results of
Furthermore, the income profile of
Regarding religion, the current program has noticed that one in two donors to
However, while some religions such as Spiritism make body donation desirable and comfortable for their followers, this decision does not need to be considered contrary to other types of faith and religious beliefs [46, 55]. The information can demystify the process, show its importance and increase the number of donors from different religions. This reinforces the need for actions to clarify and raise awareness among the population, which was decisive for the
The collected data suggest that the prevailing profile among donors for
The challenges of creating a body donation program are numerous, but the results are worth it. Some important suggestions can help the process. First, to form a team of human anatomy professors and students who value the body donation for teaching and research. Second, to deeply study the ethical principles involved in body donation; thirdly, to access all information about the legislation that regulates the body donation at the location of the program creation; fourthly, to take advantage of the experience of bequest programs already operating in the host country and abroad; fifthly, to develop a population raising-awareness strategy based on the specific characteristics of their citizens. Furthermore, once the program has been created, it is worthwhile, as soon as possible, to profile the donor and modify the publicization strategy if necessary.
Lastly, there are some limitations in this study, which include the currently short running time of the program and its application in a single university, which restricts the sample numerically. Broader studies, with a larger longitudinal reach, may complement the data and allow this experience to be more faithfully foretold in other contexts. However, in the UFJF scenario,
In conclusion, considering that the UFJF Department of Anatomy has not received unclaimed bodies for ten years and
The description of the creation and the publicizing of
The authors would like to acknowledge the staff of the UFJF Department of Anatomy, especially the collaborators José Otávio Guedes Junqueira, Valdeci Manoel de Oliveira and Simone Moreira de Macedo, in addition to all the students who participated in the outreach project linked to the
Conceptualization: AGFO, ABR. Data acquisition: AGFO, AFG, JNS, LHNS, BSS, MVP, LFSC, MSC, LCFG, ABR. Data analysis or interpretation: AGFO, AFG, JNS, LHNS, BSS, MVP, LFSC, MSC, LCFG, ABR. Drafting of the manuscript: AGFO, AFG, JNS, LHNS, BSS, MVP, JLOR, GCA, LFSC, MSC, LCFG, ABR. Critical revision of the manuscript: AGFO, JNS, LHNS, BSS, MVP, JLOR, GCA, ABR. Approval of the final version of the manuscript: all authors.
No potential conflict of interest relevant to this article was reported.