Reviews Personal views

Learning to let go of our organs

BMJ 2001; 322 doi: (Published 10 February 2001) Cite this as: BMJ 2001;322:373
  1. Derek Roskell, consultant pathologist
  1. John Radcliffe Hospital, Oxford

    We don't need to live next to a faulty crematorium to inhale bits of dead people. On an atomic level, every breath we take contains stuff that was once someone else.

    So what claim do we have, during the period between death and atomic recycling, on the physical material that used to be ours?

    For those who believe in literal resurrection of the body the claim is total. The body must be buried complete or it won't work properly next time. But few truly believe this. Even the ancient Egyptians preserved the body's external appearance while removing organs and replacing them with sand and cloth. Throughout history the emphasis has been on preserving appearance, leaving the messy inner details to the gods.

    The body and its components have gained the holy quality previously reserved for relics

    So why should most of us care what happens to our livers when we've finished with them? Mine can go to the worms, or preferably to one of my desperately ill fellow humans who needs a transplant. My friends can say goodbye to the bits of me they knew—the face, the skin, the outside. None of them has been particularly familiar with my internal organs during life, so I don't really want them to start worrying about these things after my death.

    There is a desperate shortage of organs for transplant. Before Alder Hey there was a growing campaign to allow organs to be removed without explicit consent, providing the dead person never objected. This already happens in some countries. The level of consent leading to a body being buried without some organs could be low, or even absent, because someone else would be helped. If the organs were not used, or failed, the family would not expect them to be returned, or given a funeral, any more than they would expect it for an appendix removed during life.

    After Alder Hey there is no more debate. It would be wrong to take even small parts of those organs to help others by education, research, or transplant.

    We are now told that taking tissue may be a criminal act. Do not education and research save lives? Shouldn't pathologists investigate deaths fully? We are in danger of encouraging duality in a public that is only too happy to see doctors as both villains and saints.

    Death, like eating roast chicken or going to war, is an area in which no absolutely kind or wholesome things happen, only those that are perhaps not as bad as the alternatives. If we really want to know all that happens concerning death, then, as with slaughtering birds or killing people, with that knowledge comes responsibility we might not want.

    Few would want to be asked whether a dead relative should have her orifices stuffed to prevent leakage. I would not want to be offered instead of a coffin the small bag that was enough for the remains of a friend following a fire. I don't want anyone to ask whether I want the road scrubbed to pick up the last bits of brain, or whether the little they found on the tyres would do. Traditionally the public has seemed not to want to know, and doctors, along with undertakers, crematorium and cemetery staff, clergy, nurses, and others, have been happy not to raise these issues.

    Somehow, though, the body and its components have recently gained the holy quality previously reserved for saintly relics. Perhaps beatification of the physical parts, rather than of the spiritual person, reflects a belief that the physical is all there is. Perhaps it is a denial of death itself. The alternative, that the current climate is founded on materialistic ideas of ownership, theft, and control, is too sad to contemplate.

    Like most things concerning death, the thought of tissue being taken from a corpse is uncomfortable. Medical politics is a fairy tale world with simple problems and simple solutions. Questioning and informing public attitudes to death and the body are far too difficult compared with endowing dead organs with the same legal protection as a living child.

    So now we enter the era of the two-page autopsy consent form. Perhaps the public will relish responsibility for all those choices: “So, you don't mind an autopsy, and tissue samples can be taken for research but not teaching, provided they are less than one centimetre and no more than ten pieces, and that they are used within six months. Now what would you like to do with the bits after we've used them? You're not going to change your mind or worry later are you? Oh, sorry, the transplant team has just dashed through. They've taken all the organs anyway.”

    As for me, how would I want my body to be disposed of? Well, the transplant surgeons can take what they need. If anyone wants an autopsy I hope my wife will be able to sign a form saying, “Do whatever is of any use, but spare me the details.” Then, if I am cremated, and even if I am not, I want to be scattered over Tony Blair at his party conference. If that might get someone into trouble I really don't mind where or how I am buried, incinerated, or flushed, or if I am kept on the shelf for the education of others. I can't, after all, hang on to this physical stuff forever.

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