Skeletons in the closet: time to give human bones acquired by health practitioners for educational purposes the respect they deserve

Health authorities need to develop a nationally consistent, sensible, ethical and jurisdictionally feasible process for disposal of educational human bone sets

The study of anatomy is integral to the study of medicine. It lies at an interface between the need for body parts for research and education and the ethical responsibility to show respect for the dead.1 In the 20th century, human skeletons were acquired on a mass scale as medical students were encouraged to purchase sets of human bones. Attempts to institute a legal market were overtaken by traders using illicit international sources, particularly India, as demand outstripped supply.2 The ethical, legal and practical issues were largely ignored.3

Although guidelines exist for the management, return or disposal of curated collections of human remains, the lawful disposal of human remains (including bone sets) can be problematic for doctors.4 A legal framework for disposal of legally acquired human remains that are in private ownership in Australia has not been articulated.

Little is known about the number of human skeletons in private possession in the Australian medical community. Also, there are scarce data about doctors’ knowledge of their origins, the legal framework for possession and ongoing use, and attitudes towards relinquishment.

Ethical framework

The ethical principle of autonomy asserts that people should have the right to make decisions about matters that affect them, including how their body is used or disposed of after death. On this basis, explicit consent would be required for human remains to be used for educational or scientific purposes. There is substantial anecdotal evidence that consent for people’s bones being used as educational bone sets was not obtained. Medical ethicists assert that in the absence of consent, anatomical specimens (including bone sets) should be destroyed.5 The competing claim used to justify their use — that the benefit to society of educating health practitioners outweighs individual autonomy — is hard to justify, especially because high quality replica bones (eg, by three‐dimensional printing) are now available.6

The ethical principles extend to how bone sets are stored and circulated. The fragmentation and conservation of body parts (eg, into bone sets) objectifies the remains.7 Bone sets are often stored and change hands like objects, with little thought to respect or dignity for the person to whom they belonged. A related issue is whether it is ethical to gift bones to someone else. The principles of autonomy and justice suggest that this is not the case. The holder of the bones does not have consent to hold them or to pass them on, irrespective of the intended usage.

Legal framework

It is not illegal in Australia to own human bones. The handling of human tissues in Australia is governed by the Human Tissue Act 1982 (Vic) and jurisdictional equivalents.8 While there are some minor variations between the Acts, none of them specifically address private ownership of human remains for educational purposes. Importantly, the Acts make it clear that it is illegal to sell or buy human tissue (including bones) except by a holder of a permit under the Act. It is not illegal to gift human bones to someone else.

There is a legislative requirement in Australia that human remains must be identified before cremation or burial.8 This information is impossible to obtain for purchased bone sets due to a lack of documentation or knowledge of their origin. A potential role for coroners in authorising burial or cremation has been raised, but whether they have jurisdiction is unclear.

Donation to authorised institutions such as anatomy schools has been suggested as an alternative method of disposal.9 There is no readily available information on whether this is feasible in Australia or on what scale.

The disposal of bones by unauthorised cremation (eg, fire in a backyard), burial or disposal in garbage (or similar) runs the risk of triggering a homicide investigation.10,11 This is not only costly to the community but may cause inconvenience, cost and anxiety to the disposer while investigations that establish the origin of the bones are undertaken.

Key findings of research

Three studies were conducted exploring inter‐related issues about the possession and disposal of human bones. We surveyed medical practitioners, coroners and anatomy schools. The research was approved by the Monash Health Human Research Ethics Committee (LNR/17/MonH/242).

Survey of medical practitioners

We conducted an internet survey of doctors working in two large metropolitan health services in Melbourne, Australia, exploring prevalence, knowledge and attitudes towards the personal possession of human skeletal remains. The survey was deployed using SurveyMonkey and was conducted between July and September 2017 (Supporting Information, table 1). Quantitative data were analysed using IBM SPSS Statistics for Mac (version 23). Qualitative analysis of free text responses was performed using thematic analysis.

The demographic data of respondents are shown in the Supporting Information, table 2. Despite a low response rate (373/3774, 10%), we identified several interesting findings (Box 1 and Box 2). Forty‐four per cent of respondents (163/373) had acquired human bones for their medical studies. This was more common in doctors aged over 45 years. Of those who had acquired human bones, 50% (81/163) still had them in their possession. Of those who retained the bones, 33% (27/82) reported that they had considered relinquishment and 40% (33/82) were either somewhat or very unwilling to relinquish them. Reasons for retaining bones included (multiple options were possible) continued educational use (34/82, 42%), wanting to give them to a relative studying health science (32/82, 39%), sentimental value (25/82, 30%), and that biological bones were difficult to replace (21/82, 26%). Regarding intended methods of relinquishment, 19% (14/75) intended to gift them to a health science student, 29% (22/75) planned to donate them to a university, and 52% (29/75) reported not knowing what to do.

Of doctors who had relinquished bones, 38% (31/82) had been gifted to either a relative or another health science student, 33% (27/82) had been sold, 11% (9/82) were returned to a previous owner, and 7% (6/82) had been donated to a university. In a few cases, bones had been donated to a hospital, thrown out, lost or stolen.

Survey of coroners

Coroners in all Australian jurisdictions were surveyed and asked two questions:

1. ▪ What is the recommended process for relinquishment of human bone sets in that jurisdiction?
2. ▪ If it is via coronial services:
   1. ▶ what processes are required of a health professional or their family?
   2. ▶ what processes do coronial services undertake?

Responses were received from six jurisdictions (6/8, 75%) (Box 3). They demonstrate variation in practice and processes and lack of a clear national approach.

In Queensland and South Australia, disposition of bone sets is not dealt with by coronial processes. Processes in New South Wales, Victoria, Tasmania and Western Australia are broadly similar. Bones sets are surrendered to coroners or police along with a statement of the circumstances. The bones are examined to confirm they are human, their age, gender and ethnicity, when death occurred, and whether the bones are identifiable. After this, disposal can be authorised, either by donation to a university or by cremation.

Some coroners expressed doubt about whether they had jurisdiction because it was likely that death occurred outside their state and at an unknown (likely distant) time.

Survey of anatomy schools

An online survey was sent to all Australian anatomy schools focusing on acceptance of donated human bone sets, with responses received from 24. Twenty‐one schools (21/24, 87.5%) reported that if they were contacted by a doctor or their family with a request to donate a bone set, it would be accepted. Three schools (3/24, 12.5%) did not accept donations. Reasons for non‐acceptance included limited storage, lack of a forensic anthropologist, absence of an anatomy museum, and that relinquishment to the coronial service was more appropriate.

Several schools required a formal statement regarding original acquisition and intention of donation. Most reported that bones would be examined by a forensic anthropologist to exclude Australian Indigenous origin. Importantly, it was reported that acceptance of donation depended on the condition of the bones and the school’s need for bones for teaching purposes.

Time for change

Our research shows that there is a significant but unquantified number of human bone sets circulating in private ownership within the Australian medical community. There are strong ethical reasons why this number should be reduced, preferably by voluntary relinquishment.

Our survey of doctors had a low response rate, which is not unusual in anonymous internet‐based or email surveys.12 Nevertheless, our findings suggest that doctors lack knowledge regarding the ethical and legal issues relating to possession of human bones and approaches to their legal disposal. Free‐text responses demonstrated a range of emotional and other responses and uncovered at least one unauthorised disposal. The attitudes reported by doctors suggest that bone sets could potentially circulate in the community indefinitely, with no prospect of respectful disposal. We also found jurisdictional variation in authorised disposal processes. The responses of anatomy schools suggest that while they accept occasional donations of bone sets, this is not a suitable model for large‐scale relinquishment.

Determining the origin of human remains is important, particularly whether they are of First Nations origin. The Commonwealth Aboriginal and Torres Strait Islander Heritage Protection Act 1984 includes specific provisions relating to the discovery, assessment and disposal of human remains of First Nations people.13 Key principles include consultation with local First Nations people to determine the proper actions to be taken, returning the remains, or otherwise taking direction as to their appropriate disposal or storage. States and territories have legislative frameworks, some of which consider human remains under law protecting objects of significance, while others involve coronial and public health legislation.14

Coordinated and accessible programs for managing the legacy of human bone use in education are lacking. To address this effectively, health authorities need to review legislation and develop a sensible, ethical and jurisdictionally feasible process for disposal of educational human bone sets. This will require consultation and cooperation between coroners, police, universities and doctors.

Once a nationally consistent process has been developed and legislated, specific information for doctors or their surviving relatives should be made freely available and widely publicised. Finally, the medical profession and health authorities should initiate a campaign to encourage doctors to dispose of privately held human remains.

Let them rest in peace.

Box 1 – Responses from surveyed medical practitioners regarding legal and ethical issues (n = 373)

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