Project III: Medical History / Medical Ethics

(Head of project Professor Dr. Dr. Dr. Dominik Groß)

• Sub-project III a) Medical History
  
• Preliminary results
  
• Sub-project III b) Medical Ethics
  
• Preliminary results
  
• Team
• Contact

Sub-project III a) Medical History: Research Questions

The present debate on “insufficient” autopsy rates takes place mainly within the medical profession. The relevance of the autopsy for medicine and health policy is well examined. However, the historical dimension of the debate is largely ignored and the reasons for the low autopsy rate in Germany as well as its further decline are hardly known.

From this starting point, we investigate significant explanatory factors in contemporary history. We reckon that value judgements and legal framework conditions, which evolved historically, play a significant role. It can be shown that the debate of medical specialists on the insufficient acceptance of autopsies reaches back to the 1950s, and in particular cases even further. Physicians also criticized the legal state of affairs concerning autopsies.

Furthermore, the debates on the introduction of a transplantation law and the acceptance of the brain death criterion since the 1970s are closely connected with the autopsy debate, and we assume that autopsy practices in the medical system have changed.

Medical History aims at contributing a systematic analysis of all factors since World War II, which - from the perspective of medicine and the health system - influenced the present status of the autopsy. 

Preliminary results:

Autopsy history after World War II is shaped by ongoing criticism concerning decreasing and insufficient autopsy rates. This criticism, which is uttered pre-eminently by medical associations, also refers to the lack of national autopsy regulations and to the circumstances under which an autopsy is legitimate, such as the obligation to obtain consent from the relatives.

In the analysed media, the terms “clinical”, “anatomical” and “forensic” autopsy were hardly used selectively. Also, the topics “clinical autopsy” and “harvesting organs for transplantation” were frequently addressed together. Both phenomena arguably increase the difficulty to come to an unbiased judgement concerning the positive and negative features of clinical autopsies.

An analysis of decision-making processes in the German Federal Republic since the 1970s showed, that in politics, the advancement of transplantation - a therapy which saved lifes or at least improved the quality of life - gained a higher rank than the introduction of autopsy rules. By an amendment of the German constitution in 1994, federal legislation obtained the competency to regulate transplantation issues, which led to a transplantation law in 1997, whereas the clinical autopsy remained in the competency of the individual states and, up to the present day, has been regulated only in a part of the states.

An investigation of the pathologists’ occupational image showed, that clinical autopsies lost their relevance for the pathologists with the advance of new methods in histology, cytology and molecular pathology.

An increasing interest to donate one’s body to anatomical institutes after the discontinuation to pay funeral allowances as well as an increasing diversity in funeral practices provide evidence that the attitude to deal with one’s own body has been changing in the last decades.

Sub-project III b) Medical Ethics:

From the perspective of medical ethics, the autopsy issue in Germany has been addressed marginally at best. Most notably, references are found in contributions, which address specific legal issues and implicitly also ethical aspects. Ethical implications of the autopsy issue are also briefly mentioned in bioethics encyclopaedia contributions. The starting point of our analysis is the debate between advocates of autopsies (mainly physicians) and their opponents. From the perspective of medical ethics, we are also interested in the attitudes towards dying persons in institutions as well as the attitudes of health professionals towards dying patients, and the subsequent effects on the autopsy issue in society.

The sub-project aims at developing outlines for an adequate public approach of the subject from an ethical perspective.

Preliminary results:

An analysis of the debate on clinical autopsies, including the lines of argument, showed, that critics of autopsies preferably use arguments from individual ethics. They argue that the personality rights continue to be valid after death. Some critics emphasize that autopsies lead to a violation of the integrity of the human corpse, to contradict religious beliefs, or to constitute an offence against appropriate reverence or burial rituals. A further argument refers to the costs for autopsies, which would, against the background of the finanically strained health system, be of better use for the living (distributive justice).

The majority of physicians support autopsies, as an analysis of the journal of the German medical profession “Deutsches Ärzteblatt”, showed. They mainly refer to arguments from social ethics, and point out, that autopsies constitute an advancement of knowledge and thereby an altruistic service of the dead for the living. They emphasize the need of autopsies for health quality assurance, target-oriented health care governance, and the appropriate allocation of resources.

Furthermore, it could be shown that - especially in the debate within the medical profession - there are various definitions for the status of the dead body and the corresponding practices, but that these definitions are hardly demarcated from each other. In many cases, the term “human dignity” is used with direct reference to the dead body, although the dead body lacks the status of a person. The terms “postmortal (human) dignity” and “human dignity after death” are applied as well. From these terms, “dignity of the dead” must be demarcated. “Dignity of the dead” is used more recently, predominantly in the context of new funeral regulations, and references to social practices concerning the dead body. Conceptually and linguistically, the term “dignity of the dead” refers to human dignity as the overarching characteristic of all living human beings. It denotes that the dead human body is worthy of protection, but it is not synonymous with “human dignity”.

Referring to Avishai Margalit’s social concept of human dignity, a concept for the dignity of the dead was devised, which is not founded on typically human characteristics or membership of the human species, but on the relationship aspect of human dignity: the social interaction.