A belief in the soul may contribute to the stress experienced in the dissecting room

Abstract

The aim of this research was to explore whether medical students believe in a soul and how this may affect their dissecting experience. Three questionnaires were delivered electronically to the 2011 cohort of second-year medical students over a 2-year period. At the University of Otago, students enter medicine via three categories: Health Sciences First Year (following 1 year of university); postgraduate (following a Bachelors or higher degree); and ‘other’ category entry (Allied Health Professional or 3 years after a Bachelors degree). The entry category, age, ethnicity and gender of the students were collected; 51.6% of the students believed in the concept of a soul. On a scale of 1–5, students ranked the importance of religion/spirituality as 2.69. Those who believed in a soul were more likely to have a religious/spiritual component to their life and be males or ‘other’ category entrants. However, there were many students who believed in the soul who did not have a religious/spiritual association, suggesting that this belief extends beyond religion. Those who believed in a soul had significantly higher anticipatory stress and experienced higher levels of stress during dissection. A higher proportion of students in the ‘other’ category entrants believed in the concept of the soul and also had significantly higher levels of stress during dissection. Our data suggest that a belief in a soul may affect students' experiences in dissecting. Incorporating the teaching of humanities with anatomy may help medical students as they assimilate both the biomedical and philosophical aspects of dissection.

Introduction

The production of a documentary film ‘Donated to Science’ (Trotman & Nicholson, 2009), which involved interviewing medical students during their dissecting laboratories, identified that some students believed in the concept of a soul and that this belief may have affected their learning in the dissection room (Martyn et al. 2012). The origin and understanding of the concept of the soul has been discussed for many centuries (Santoro et al. 2009). From the ancient Egyptians through to great Western philosophers and teachers, such as Socrates, Plato and Aristotle, and then the beginnings of the major religions including Christianity, the search of the soul has continued with no definite answers (Santoro et al. 2009). A common theme throughout these historical findings has been a search for a soul or an understanding of the greater world. As part of this journey, much of our understandings around anatomy and the human body have also been discovered.

Despite the longstanding discussions of the soul, a common, agreed definition of the soul does not exist. Many of the differences in the description are related to how the soul interacts with the body. Thus, Aristotle and his followers argue that the soul and body are physically inseparable, while Plato described the dualistic view of a separate immortal soul held within a mortal body (Murphy, 2006). This view was held by the early Christian church, but more recently a trichotomistic description has been put forward that suggests that the soul exists in a relationship with both the body and spirit (Murphy, 2006).

In our earlier qualitative study, medical students expressed some rather idiosyncratic beliefs related, in particular, to the dissection of the heart and brain, and the origin of the seat of the soul (Martyn et al. 2012). This small cohort of 16 students revealed what have been described as ‘naive’ and ‘disconcerting’ views, and showed a lack of understanding around philosophical and ethical issues that can be linked to dissecting (Jones et al. 2012). The students seemed to place an exaggerated importance on the dissections of the heart and the brain relating to emotional connections to these organs, and many identified the heart and the brain as the origins of the soul. They described the personal nature of these dissections and their distress at ‘cutting through a person's consciousness’. This qualitative research had a limited number of students, and the themes related to the seat of the soul were discovered in a retrospective analysis (Martyn et al. 2012). This may have led to an unrepresentative understanding of what medical students believe about dissecting the heart and the brain and their views on a soul. To comment more fully on students' understanding of the concept of a soul, further study was undertaken. This study was in two parts, and included both a quantitative and qualitative component. The qualitative component explored students' definition of the soul. Students often described the soul as the ‘life force’ or the ‘spiritual essence of a person’ (Martyn et al. 2013). While many students held a dualistic view of the soul, there was a wide range of interpretations of the soul (Martyn et al. 2013).

The aim of this current paper was to identify whether the concept of a soul was important to a larger cohort of students, and whether or not the students' ideation of a concept of the soul affected their dissecting experience. We hypothesised that a belief in a soul may help students reduce the stress of dissection.

Methods

At the University of Otago, students enter into the second year of the medical course either from a Health Science First Year (HSFY), immediately following an undergraduate or postgraduate degree, or via an ‘other’ category. The HSFY entrants have completed a single year at university studying specific Health Science papers, the postgraduate entry category are students who enter immediately after an undergraduate or postgraduate university degree, and the ‘other’ category are those students who enter either as an Allied Health Professional or after more than 3 years following the completion of a Bachelors degree. At the University of Otago, students receive a preliminary orientation lecture and small group work around death and dying and the ethical uses of cadaveric material before starting dissection. Many also attend a ‘whakawatea’ (Clearing of the Way Ceremony) in the dissection room at the beginning of the programme. The 2011 cohort of 267 second-year medical students at the University of Otago was invited to participate in this research. Cover letters and informed consent to participate in three surveys over 2 years was gained, and ethical approval granted by the University of Otago's Human Ethics Committee. The first survey occurred prior to the first dissecting laboratory, the second soon after the students' first dissection (of the musculoskeletal system) and the third at the end of the 4th (last) semester of studying Anatomy. The surveys were run through SurveyMonkey™ and had both five-point Likert scale responses and free text questions, and included data in relation to demographics and ethnicity. The surveys are being used to address several research questions to assess students' beliefs around the concept of a soul and attitudes towards dissecting. The questions asked in relation to this current study are shown in Table 1.

Table 1.

The questions relevant to this study that were asked in the surveys.

Survey 1, prior to entering the dissecting room
How do you feel about death?
I haven't thought about it
It scares me
I'm comfortable with it
Do you have a religious or spiritual component to your life?
No	A little	Neutral or some	Yes, faith is important to me	Yes, very much so
Rank your level of stress towards thinking about going into the dissecting room
No stress	A little bit of stress	Moderate levels of stress	Stress	Very stressful
Survey 2, after the first dissection
Rank the level of stress you experienced in the anatomy room during the first session
No stress	A little bit of stress	Moderate levels of stress	Stress	Very stressful
Do you have a religious or spiritual component to your life?
No	A little	Neutral or some	Yes, faith is important to me	Yes, very much so
Do you believe in the concept of a soul?
Yes	No	Don't know
Historically people have believed that the soul may be located in different parts of the body. Where do you perceive the soul to lie?
Heart	Brain	Liver	Stomach	Not in any organ	Other
If applicable, please describe your understanding of the soul
Survey 3, during the last semester of Anatomy teaching
Rank your level of stress experienced in the dissecting room
No stress	A little bit of stress	Moderate levels of stress	Stress	Very stressful
Do you have a religious or spiritual component to your life?
No	A little	Neutral or some	Yes, faith is important to me	Yes, very much so
Have your beliefs changed since you have been in the dissecting room?
How would you best describe your current beliefs?
I hold a set of religious beliefs; I hold a set of spiritual beliefs; My beliefs are both religious and spiritual; No particular beliefs
Do you believe in the concept of a soul?
Yes	No	Don't know
Has your understanding of the soul changed in the last 2 years?

The questionnaire was distributed to students: (1) prior to their first dissecting laboratory; (2) after the first dissection; and (3) in the last semester of Anatomy teaching.

The results of this study were collated in Microsoft Excel, and data analysed and graphs created using graphpad prism. Data were analysed either by one-way anova followed by post hoc Bonferroni test, unpaired Student's t-test or Fisher's exact test.

Results

In the 2011 cohort of 267 second-year medical students, there was a response rate of 64.4% for the first survey, 73% for the second and 40% for the third surveys. Most of the students at the beginning of the study (51.6%) believed in a concept of a soul compared with 27.5% who did not and 20.9% who were unsure whether they believed in the concept. The process of dissecting did not appear to alter students' belief in the concept of a soul, with a similar distribution of responses at the end of 2 years study of Anatomy.

We investigated whether there was a relationship between a belief in a soul and a student having a spiritual/religious component to their life. Students rated the religious/spiritual components in their life (Fig. 1) on a scale of 1–5 (1 = none; 2 = a little; 3 = neutral/some; 4 = faith is important; 5 = faith is very important). The mean score in the class was a rating of 2.69 (between ‘a little’ and ‘neutral/some’).

Figure 1.

The level of religious/spiritual components in the students' lives when scored on a five-point Likert scale (1 = none; 2 = a little; 3 = neutral/some; 4 = faith is important; 5 = faith is very important). n = 190.

Further analysis of whether a belief in a soul was related to the level of spirituality was explored. In the students who believed in the concept of a soul, the mean rating of religious/spiritual components was 3.59 (between ‘neutral/some’ and ‘faith being important’) compared with 2.06 (close to ‘a little’ religion) in the group who were unsure of their belief in a soul and 1.26 (between ‘none’ and ‘a little faith’) in the group who did not believe in the concept of a soul (P < 0.001; Fig. 2). There was no difference in the importance of spirituality and the entry category of the students (data not shown). There was a statistically significant difference between the level of spirituality and the gender of our students, with females having an average score of 2.90 compared with males with only 2.32 (P = 0.0009; Fig. 3).

Figure 2.

The relationship between students' belief in a soul and having a religious/spiritual component in their lives: ‘believes in soul group’ n = 98; ‘unsure if believes’ n = 52; and ‘does not believe group' n = 38. Data were analysed by one-way anova followed by Bonferroni test.

Figure 3.

The level of religion/spirituality in male and female students. n = 109 females, n = 82 males. Data analysed by Student's t-test.

Some differences in whether students believed in a soul or not appeared to be related to ethnicity, but the sample size in some groups was too few to undertake a meaningful statistical analysis. The belief in a soul also differed depending on the gender of our students, with males more likely to believe in the soul (Fig. 4; Fisher's exact test of P = 0.0280 when comparing the ‘believe in a soul’ with the ‘does not believe’ group comparing the two genders). There also appeared to be a difference within the entry category of our students, with the students entering from the ‘other’ category more likely to believe in the soul, with none of these students stating that they did not believe in this concept (Fig. 5). However, it should be noted that the number of students in this group is small and statistical analysis was not performed (HSFY 135, graduates 34, other 13).

Figure 4.

Differences between males and females in regards to a belief in a soul (Fisher's exact test P = 0.0280).

Figure 5.

Differences in the belief in a soul depending on the entry category of the students into the course.

Students were asked about their belief in the origin of the soul. Of those students who responded to this question (85.6%, 167 of 195 participants of the second survey), most thought that the soul did not originate in one organ of the body (82%), with others stating that the origin of the soul was in the heart (10.8%), the brain (11.4%) and one student identified the liver (0.6%; Fig. 6). No other organs were mentioned by students as possible origins of the soul. The 28 students who did not answer this question had previously stated that they did not believe in the soul. Although only 11% of students believed that the brain was where the soul resided, at the end of the dissection 65% of students felt that the brain was a more special organ compared with the heart (5%). The belief in the location of the soul was also different depending on the importance of a religious/spiritual component to the student (P = 0.0051). The students who believed that the soul did not lie in one organ had a mean religious/spiritual Likert score of 2.99 compared with those who identified the heart, brain or liver who had a mean score of 2.24.

Figure 6.

Where do students perceive the soul to be located?

Students were asked prior to the first laboratory session about their level of stress in anticipation of going into the dissection room, and asked again following the first dissecting session to rank their level of stress experienced during the dissection (1 = no stress; 2 = little stress; 3 = moderate stress; 4 = stressful; and 5 = very stressful). There was a significant increase in the average level of stress in the students who believed in a soul vs. the students who did not (P < 0.05) in both their anticipation towards the laboratory and the stress experienced in their first dissecting experience (Fig. 7). There was no significant difference between the anticipatory stress and the experienced stress.

Figure 7.

Students' level of stress: (a) prior to; and (b) following the first dissection and their belief in a soul. Data were analysed by one-way anova followed by Bonferroni test.

There was also a significant difference between the level of anticipatory stress in the female students (average level of 1.90) compared with the male students (average level of 1.63; P = 0.0152; Fig. 8a). However, the actual level of stress experienced did not differ between genders (Fig. 8b).

Figure 8.

The levels of stress: (a) before; and (b) during dissection in male and female students. Data were analysed by Student's t-test.

There was no difference in the anticipated stress experienced between the various entry categories of our students. However, the ‘other category’ entrants experienced significantly more stress during the dissection than the HSFY and postgraduate students (Fig. 9).

Figure 9.

The level of stress in the entry categories: (a) before; and (b) during dissection. No difference prior to dissection was observed, but statistically significantly more stress was reported in the ‘other category’ students during the dissection. Data were analysed by one-way anova followed by Bonferroni test.

Discussion

In our cohort of second-year medical students, about half of the students (51.6%) believed in the concept of a soul and, differing from our earlier data from a group of only 16 students (Martyn et al. 2012), this belief in a soul was associated with the level of religious/spiritual associations held by the students. While many of the students expressed some level of religious or spiritual belief, 30.5% of our sample identified themselves as having no religious/spiritual component to their lives. This is similar to the general New Zealand population, as shown by the 2006 NZ census where 34.7% of the population stated no religious associations (http://www.stats.govt.nz/Census/2006CensusHomePage/QuickStats/quickstats-about-a-subject/culture-and-identity/religious-affiliation.aspx). When the students who expressed a religious or spiritual component to their lives were asked to describe their beliefs, 6% declared they held a set of religious beliefs, 55% spiritual beliefs, and 38% held both religious and spiritual beliefs. However, a belief in the soul was not dependent on religious/spiritual associations, and many students who professed to have no or little religious/spiritual associations also believed in the concept of a soul. Interestingly, while females reported a higher score on the importance of a religious/spiritual component in their lives, more males believed in a soul. It would thus seem that a belief in the soul is not necessarily dependent on a person's religious/spiritual belongings. and the concept of a soul is accepted outside of religious beliefs. Peck (1997) defines the soul as ‘God-created, God-nurtured, unique, developable, immortal human spirit’. This definition fits with a religious belief of a soul, but our data show that some students have an understanding of a soul beyond religion. Others have suggested that the idea of a soul being ‘separable from the body’ is not necessarily related to religious beliefs (Green, 2008). Our data show that the belief in a soul varied with the gender and the experiences of our students (other category entrants differed from our HSFY and postgraduate students). This again shows that more than just religion/spirituality may contribute to a person's concept of a soul.

The students' thoughts on the origin of the soul were also associated with their spiritual/religious associations, with those students who identified the soul's origin in the heart, brain or liver reporting a lower level of religious/spiritual association. However, the majority of participating students (82%) believed that the location of the soul could not be confined or located to a single organ. This contrasts with our earlier small qualitative study where approximately half of the students interviewed felt that the brain or the heart was either the seat of the soul or had special meaning to them (Martyn et al. 2012). It was interesting that while students did not believe that the brain was the origin of the soul, many perceived it to be a more special organ than the heart.

Prior to the study we had hypothesised that a belief in a soul may make it easier for a student to enter the dissecting room. However, our data show that a student's belief in the soul was associated with an increase in the perceived level of stress that they anticipated and experienced in the dissecting room. Those believing in a soul had significantly higher levels of stress than those who did not believe in the concept. The reasons behind this are not clear. It may be that the students of faith still consider the body as a sacred vessel that carried the soul and are concerned a physical soul is still attached to the body. Furthermore, students who believed that the soul resided in the heart or the brain were less likely to hold religious or spiritual convictions and had lower levels of stress even when dissecting the organ that they believed held the soul.

The level of stress anticipated and experienced in the dissecting laboratory also varied according to the gender and entry category of our students. Females had higher anticipatory stress, despite the observation that females were least likely to believe in the concept of a soul. Others have found that females express higher concerns over stimuli in the dissecting room, such as smell and sight of the cadaver (Abu-Hijleh et al. 1997; Snelling et al. 2003; Bataineh et al. 2006; Azer & Eizenbery, 2007). Female students express more fear around entering the dissecting room and have displayed higher physical and emotional reactions to the act of dissecting (Abu-Hijleh et al. 1997). Unlike these other groups of students, our cohort's level of reported stress in the laboratory itself did not differ between males and females.

A range of ages and backgrounds are other factors that may affect students' responses to the dissecting laboratory. Azer & Eizenbery (2007) found that their older postgraduate students displayed less concern over the laboratory's smell and had less symptoms of nausea compared with their younger colleagues. Others have also found that the emotional response of loss was higher in the younger non-graduate students (Vijayabhaskar et al. 2005). It has been proposed that the older students are more emotionally mature, and many have been exposed to death or the act of dissecting (e.g. in a biology degree), which helps them cope with the dissecting laboratory experience (Vijayabhaskar et al. 2005). However, we found that the older students who entered via the ‘other’ category entry scheme reported experiencing significantly higher levels of stress in the dissecting laboratory. This group was much smaller than the other two entry categories and further data are required to confirm this difference. These students are also potentially more isolated than other students who often have established friendships with their peers when they enter the medical programme. Kotze & Mole (2013) have shown that one of the most commonly used coping mechanisms for dealing with dissecting is talking with peers. This may also explain why their anticipated level of stress did not differ from other groups. The cohort of ‘other’ category students did represent a higher proportion who believed in the concept of the soul despite no difference in level of religious/spiritual associations. This increased belief in the concept of a soul may also contribute to these students' discomfort and stress in the laboratory. It would be interesting to compare our group of students' belief in the concept of a soul with the belief of those older students at other schools whose maturity and experience seem to enable them to cope better with dissection.

The data suggest that having a religious/spiritual component to one's life and a belief in the soul may make dissecting more stressful and potentially have negative effects on anatomy learning. Alternatively the converse may be true and a lack of religious/spiritual belief may reduce stress levels. Consideration of spirituality is increasingly being recognised as important in the provision of health care (Egan et al. 2011).

Our data suggest that a sizable proportion of our medical students have some belief in a soul. There is, however, religious, spiritual and cultural diversity present in our medical students, and a belief in the concept of a soul may be only one aspect that may affect students' attitudes towards dissecting, cadavers and death. The process of dissection transgresses many cultural and societal boundaries. It is important for teachers to recognise this diversity and the effects it may hold for learning anatomy. Furthermore, opportunities for students to explore more formally the philosophical, spiritual and cultural understandings of the human body may help prepare them for dissection and their roles as future doctors.

Author contributions

Helen Martyn is a Trainee Intern at the University of Otago, Dunedin, New Zealand. She helped in the development of the questionnaire for students, and was responsible for analysis of the results and writing the first draft of the manuscript. Anthony Barrett is a Medical Education Advisor for the Faculty of Medicine at the University of Otago, Dunedin, New Zealand. He was involved in the development of the questionnaire and was responsible for distributing this to the students. He also helped to analysis the results, identify themes and edit the manuscript. Professor Helen Nicholson is Professor of Anatomy and Dean of the Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand. She was one of the producers of ‘Donated to Science’, and was responsible for developing the questionnaire, identified the themes from the results and edited the manuscript.