‘Life after Death – the Dead shall Teach the Living’: a Qualitative Study on the Motivations and Expectations of Body Donors, their Families, and Religious Scholars in the South Indian City of Bangalore

Abstract

In India, there has been a shift from using unclaimed bodies to voluntary body donation for anatomy dissections in medical colleges. This study used in-depth qualitative interviews to explore the deeper intent, values and attitudes towards body donation, the body and death, and expectations of the body donor (N = 12), as well as their next of kin (N = 7) and representative religious scholars (N = 12). All donors had enrolled in a body bequest programme in a medical school in South India. This study concludes that body donors are philanthropists with deep-rooted values of altruism and service, who are often willing to forgo traditional religious and cultural death rituals. The next of kin are often uncomfortable with the donor’s decision, and this suggests that it is important that dialogue/counselling occurs at the time of the bequest, if the donor’s wishes are to be respected. Religious injunctions are often misinterpreted; this implies that religious leaders/scholars can play a significant role in addressing these misconceptions which are barriers to body donation. Body bequest programmes in India may be enhanced by positioning body donation as ‘daana’—giving without any expectation of return for a higher purpose, including ceremonies of respect in medical colleges. Furthermore, increased public engagement and awareness about body bequest programmes are also important to enhance participation. When medical students internalise what body donors expect of them, i.e. altruism, empathy with patients and becoming ‘good doctors’, it will help to ensure that the donation was not in vain and that the dead truly teach the living.

Introduction

The first recorded human dissection in Asia was by Madhusudhan Gupta in 1836 (Arnold 1993; Bhattacharya 2011). The absence of any law, along with widespread poverty, provided a steady supply of bodies for dissection (Pati and Harrison 2011). In 1949, the Indian government enacted the first Anatomy Act. This law attempted to regularise the procurement of bodies for dissection in medical schools across India using unclaimed bodies, legally dispensing of the need for consent (Richardson and Hurwitz 1995; Ajita and Singh 2007; Rokade and Bahetee 2013). Most medical colleges in India, in contrast to Western countries (Riederer et al. 2012), continue to receive unclaimed bodies (Prakash et al. 2006; Ajita and Singh 2007). However, with the associated medico-legal issues, as well as the growing number of medical colleges, the demand for cadavers is more than the supply (Ajita and Singh 2007; Rokade and Gaikawad 2012; Shaikh 2015).

Apart from the fact that the body is used without consent, with unclaimed bodies, there are additional ethical issues. This practice is considered unethical because these unclaimed bodies can be acquired under dubious circumstances and usually involve people at the margins of society, hence perpetuating injustice and possible exploitation (Jones and Whitaker 2012). The unintended consequence of using unclaimed bodies made poverty the sole criterion for dissection (Jones 2014). At times, cadavers have been wrongly or surreptitiously labelled ‘unclaimed’ and been distributed for dissection—this is an injustice not only to the dead, but also to their next of kin (Pampilly 2005). The use of unclaimed bodies undermines the value of human life since it violates a person’s autonomy in making such a vital decision. Newspaper articles and popular media have reported corrupt trade practices in bodies, body parts and bones (Grow and Shiffman 2017; Perappadan and Trivedi 2019). These include the secondary sale of bodies by institutions that have greater access to the unclaimed bodies. The greater than 100 unclaimed bodies per day in India has led to the commercialisation of body parts. Just before 1985, when a law was promulgated to ban this commercialisation, 60,000 skulls and skeletons had been exported out of India. This continues on a small scale in a clandestine manner, in practices such as bone smuggling (Ray 2018). These practices go beyond a violation of autonomy; they are a violation of human dignity.

Body donation, in contrast, can be considered ethical because it is voluntary, with no financial transactions involved, and where the wishes of the donor are respected (Jones and Whitaker 2012). In the case of voluntary body donation, the consent of the donor is always taken, thus making it an informed choice.

Cadavers not only teach students the details of human anatomy, but also sensitise them to the concepts of death and respect towards the human body. In India, undergraduate medical education is a four-and-a-half-year course, followed by a year of internship. The first year covers pre-clinical subjects, including Anatomy. In the first year, students have minimal contact with patients and clinical medicine. While the dissection of cadavers can be a dehumanising experience, understanding the choices and motivations of the body donor could convert this into a humanising experience. This could teach medical students important lessons that could lay the seeds for more humane, trustworthy doctors who empathise with the lives of their patients (Hafferty 1988; Rizzolo 2002; Park et al. 2011; Zhang et al. 2014; Shaikh 2015). Thus, through the use of voluntarily donated bodies for dissection, acknowledging the choice that a person and his family have made increases the potential for the development of ethically sensitive, empathetic, altruistic medical practitioners and human beings, who internalise the concepts of informed consent and respect for personhood along with the body. These characteristics of a medical practitioner are especially crucial in a country like India, where a vast majority of the population does not have access to adequate or optimal healthcare, and where there is sufficient potential for its marginalised, vulnerable and poor members to be further exploited. Furthermore, working with unclaimed bodies will lead to medical students missing out on this important lesson. It has been established that such attitudes can only be developed by working with human bodies, and not anatomical models, which are viewed as ‘objects’, and serve only as an illustrative tool (Korf et al. 2008).

In India, studies have evaluated the willingness and awareness of body donation among the general population (Rokade and Gaikawad 2012; Dope et al. 2015; Saha et al. 2015) and specifically among medical professionals (Ballala et al. 2011), but there is no published study on the motivations and expectations of body donors themselves. Other articles have reviewed the ethical issues surrounding body donation (Shaikh 2015) and emphasise the need for body donation for anatomy (Patil 2015). Blood donation as a concept receives sanction as a form of maha daana (daana meaning ‘gifting’ in Hindu law and maha denoting greatness) (Copeman and Reddy 2012) and organ donation is gaining popularity as an evolving form of biomedical daana (Rokade and Gaikawad 2012). Body donation (deh daana) in contrast has limited acceptance and is not widely spoken about (Anand 2018) because death is seen as an important ‘moment of passage’ and the rituals associated with death enable one to be freed from the cycle of birth and death (Wilson 2003; Mines and Lamb 2010). Hinduism, the faith practised by a majority of the population in India, requires the body to be purified through ‘Antyesti’ (last rites) by either cremation or burial.

The Anatomy Department of St. John’s Medical College (SJMC), Bangalore, in the southern Indian state of Karnataka established a body donation programme in 1977. In 2007 following a High Court ruling, there was a shift from using unclaimed bodies to using only donated bodies (Pampilly 2005). By mid-2016, over 900 people had pledged their bodies to the programme of SJMC and nearly 100 bodies had been received. Body donors may represent all strata of society, but in our registry, there are a greater proportion of educated, middle-class individuals who are more likely to be aware of the choice that they are making. At the start of the anatomy programme every year, an inter-religious prayer service is held with a blessing of the cadavers. The service concludes with the medical students taking an oath.

This study aimed to understand the deeper intent, values, attitudes towards body donation, the body and death, and expectations of the body donors, as well as their next of kin and representative religious scholars. Through this, it is hoped that the ethical practice of body donation will be better understood and thus better promoted. The medical student must be better sensitised and informed about the process and intent of voluntary donation as this will foster greater respect for the cadaver.

Methods

Study Design and Sample Selection

As no hypothesis was being tested and the objective of this study was to gather peoples’ perceptions of their decision to donate and arrive at their motivations and struggles in the process, it was important for the study to follow a non-positivist approach. Hence, there was no pre-conceived theory or deterministic research design. Rather, the respondents were allowed to lead the discussion and share their views on the topic through their life experiences and perspectives of life and death, and the interviewer then probed the areas that emerged. Therefore, the method chosen for the study was based on the Grounded Theory (Strauss and Corbin 1990).

Sample selection was purposive. The study design included three categories of respondents pre-decided as part of the study design. These three categories were formulated in order to obtain a holistic view of body donation—with views from the donors themselves, their next of kin, as well as scholars of religions who could provide insight about the aspects of religion concerning body donation.

Category 1 included body donors registered between May and November 2016 at the Anatomy department SJMC. Of the 41 registered donors, those whose contact details were complete and lived within geographical proximity were contacted over the telephone or were met personally at the time of their enrollment as donors. Those who were unwilling to talk or were seriously ill were excluded. Twelve donors consented to be interviewed. Table 1 provides the demographic profile of the 12 donor participants of this study as well as of all the donors registered with the programme in that period.

Table 1.

Demographic profiles of body donors

	Total donors (May–Nov 2016)	Sample enrolled in this study
N	41	12
Male	23	8
Female	18	4
Age > 60	37	11
Age < 60	4	1
Ever married	35	12
Unmarried	5	0
Hindu	29	7
Christian	10	3
Others (Jaina, Parsib)	2	2

^aJainism is a non-theistic religion of India, currently with about 4.5 million followers in India

^bParsis are followers of Zoroastrianism and number a little more than 50,000 in India

Category 2 included the next of kin of the donor (spouse, child, sibling or any other close relative). Since many of the respondents in category 1 were spouses, the next of kin, mostly a child, was common to both respondents, hence, the reduced number (N = 7). In this study, although not intended, all the next of kin were women. This could probably be due to the fact that in India, women are the primary caregivers—be it as spouses or mothers. This could also be due to the fact that almost all the donors were male, and almost all the next of kin were spouses.

Category 3 included representatives or key individuals of different religious groups (Hinduism, Islam, Christianity, Buddhism and Jainism) purposefully sampled from recognised, credible religious institutions. The selection was unrelated to the stated religions of the donors sampled. Twelve representatives with doctorates in Vedantic Philosophy, Bioethics, Religion and Philosophy, Masters in Theology and general degrees were interviewed. Certain monks had renounced their formal degrees and refused to disclose this information. Table 2 provides the religion and gender distribution of respondents in this category.

Table 2.

Profile of religious scholar respondents

Religion	Number of respondents, n = 12	Gender
Hinduism (scholars/monks)	6	Male-5
		Female-1
Christianity (priest-scholar/pastor)	2	Male-2
Jainism (scholar)	1	Female-1
Buddhism (monk)	1	Male-1
Islam (scholar)	1	Female-1
Non-denomination spiritual organisations (brahmakumari-nun)	1	Female-1

In each category, sampling continued until theoretical saturation was reached. This was achieved by initiating data analysis while collecting data.

Data Collection

Oral narratives were collected using a semi-structured interview guide with open-ended questions. Separate guides were used for the three categories (provided in the Appendix). Interviews were conducted in a free-flowing narrative format. To get to the unique features of each individual donor and to arrive at a nuanced understanding of a person’s abstract qualities, the qualitative research tool of ‘metaphors’ was used in order to elicit deep and personal accounts and help understand a familiar process in a new light (Schmitt 2005).

Interviews lasted 30–90 minutes and were audio recorded, after obtaining consent. Detailed observations and field notes were also taken. Interviews were conducted at the home or workplace of the participant or the workplace of the investigators, based on the convenience of the participant.

Audio-recorded data was transcribed by author 1 and the written transcripts checked and corrected by authors 2 and 4 who conducted the interviews. Interviewees who wanted a copy of their narrative transcript received this either electronically or in person. Interviewees were assigned numbers and have been referred to by these numbers in the paper in order to ensure confidentiality. The data collected was stored securely in a password-protected office computer designated for this study and access to the same was provided solely to the authors.

Data Analysis

Data analysis began at the time of data collection, following the Grounded Theory approach. After re-reading the transcripts and field notes multiple times, content analysis was done by giving key concepts, conceptual labels or codes. This was followed by grouping codes into more abstract categories. The primary source of data was from the body donors, and the data from the next of kin and the religious scholars was used to get insight into and to compare and contrast the aforementioned data. The method of constant comparison was used, and hence, the analysis was an evolving process (Bradley et al. 2007). Emerging relationships between categories resulted in the proposed themes presented in the Results section. An inductive-led approach guided the analysis.

Ethics Clearance

Institutional Ethical Committee approval for the study was given by the medical college. Permission to access the registry and contact the donors was received from the Head of the Anatomy Department. Author 3, a co-investigator in the study, is a faculty member of the Anatomy Department and is in charge of the Body Donation programme and the registry. The request to participate in the study was made at the time of registration and contact and consent of the donors was initiated through this investigator. Written informed consent was obtained from all participants. No payment was offered to the participants for being interviewed.

Findings

Four main themes formed the analysis framework—(i) motivations to donate, (ii) death rituals and their influence on donation, (iii) the wider purpose of donation and (iv) the expectation of reciprocity.

The Motivation to Donate

The donors had a mixed educational background—four had completed grade 12 of schooling (higher secondary), five had bachelors’ degrees and three had masters’ degrees. Seven of the eight men were retired professionals, whose previous occupations included an engineer, a banker, a teacher, an air force officer, a judge and a theosophist. Of the women, three were housewives, and one a counsellor. Through their own testimonials and the descriptions given by their family members, it appears that the lives they led and the choices they made in various phases of their lives influenced their decision to donate their body. The following allegorical constructs of the donors emerge based on particular motivations. However, because of the small sample size, it should be noted that generalised inferences cannot be made about the population of donors.

Trendsetters/Illuminators

These donors perceived themselves as people who carved their own paths and took radical decisions, setting societal norms aside.

I see myself as a point of light given by the Almighty, that can enlighten students to help them learn something new. (Donor 3, Hindu male)

Givers/Philanthropists

These were people described to be charitable by nature, and of a philosophical outlook. Many of the donors participated in philanthropic activities like blood donation, works of charity and serving underprivileged people.

It’s about doing something for society at the end of the day, even after I’m gone. (Donor 2, Christian male)

Pillars

The donors in this category were strong-willed yet adaptable individuals, who were very certain about their decision. They were flexible when it came to giving up death rituals for this cause.

There was no discussion in the family about her decision. She made the decision and only then told us about it. (Next of kin of Donor 6, who is a Jain female)

Rituals do not assure your entry into heaven. I didn’t want to waste a body that could be useful to others. (Donor 5, Hindu male)

Emulators

A fourth category was those who were emulating the decision of a role model who had donated or planned to donate their body. This person was often a loved one or a celebrity.

The main inspiration for this decision was the theatre artist Makeup Nani, who donated his body to St. John’s after his death. (Donor 3, Hindu male)

Two of the women donors fall in this category, having made their decision following that of their spouses.

Death Rituals and Their Influence on Donation

Death rituals, which are traditionally performed with the body after a person’s death, emerged to be an important barrier for the donors to overcome in the decision-making process. Some of the donors in this study perceived these rituals as futile. They felt that performing such rituals rendered the body, a perfectly viable resource, useless either by cremation or burial. ‘I didn’t want to waste my body that can be useful to others’ (Donor 3, Hindu male). They felt that by choosing to donate their bodies as opposed to carrying out death rituals, they would not only be performing the virtuous act of helping students to learn and further research, but also be reducing the generation of waste, thus rendering another form of service to the Earth.

This was voiced in a variety of ways. Among those who had strong religious beliefs—‘Once the aatma (soul) goes out of the body, it is a waste. So what difference do rituals make?’ (Donor 3, Hindu male) and ‘Rituals do not assure your entry into heaven’ (Donor 5, Hindu male). Still others, although accepting a religious identity, were sceptical about religion and their beliefs. ‘I don’t have much belief in God, or such things as hell or heaven’ (Donor 9, Hindu male). They felt that the prayers were not honest or sincere enough. Another perspective that emerged was, ‘Rituals can still be carried out without the body, using something that belongs to me’ (Donor 12, Hindu male). This is in line with positions in virtue ethics, which uphold noble behaviour and good deeds over absolute rules and rigid dogma of conventional religions (Trianosky 1990).

Most of the donors, irrespective of whether they had strong religious beliefs centering around death rituals or not, still felt that rituals were a personal affair. They had made the decision to donate their bodies keeping their families in mind, with the belief that there would be ‘no hassle for anyone this way’, that ‘the less fuss there is about it, the better. If you can do away with all the mourning and finish it off, that’s the best way’ (Donor 8, Christian female). This is because they had thought through the decision and believed that the fewer people who were involved in it, the better. This view was voiced among donors who had convinced their immediate families but were worried about what the extended family and society would have to say. They believed that ‘It is nobody’s business but mine and my immediate family’s…’ (Donor 10, Hindu female).

These strong convictions of donors were often in dissonance with family views, with the next of kin having persistent concerns. They were uncomfortable about giving up traditional rituals following death either because of religious diktats—which seemed to imply that these death rituals were central to the body and the soul achieving closure after death—or that they were worried that the body donation would be viewed by others as a mechanism of saving money that would otherwise have been spent on these rituals.

In the case of some donors in this study, when they patiently explained their decision and its motivations to their families, they were often proud and even happy with the choice made by the donors. Since it is ultimately the next of kin of the donors who have to hand over the body, it is thus imperative for them to be aware of and to understand the decision of the donor. This could further the body donation programme by encouraging effective communication between donors and their families, enabling the entire decision to be more collective.

Across religions, scholars interviewed described death rituals as being prescribed by religious injunctions. These rituals enable community bonding and in many ways, give closure to the families involved. Hindu scholars explained the rituals as a way of showing respect to the use of the ‘instrument’ (the body) for a period by the soul. The destruction of the body by cremation allowed the soul to be sent back. Most faiths highlighted the principle that the body was perishable but the soul was immortal. However, religious scholars pointed out that ‘Ignorance in understanding religious texts’ (Religious Scholar Respondent 1, Hindu) and ‘giving excessive importance to rituals rather than cultivating good karmas (actions) and mindful consciousness’ (Religious Scholar Respondent 3, Hindu) were responsible for insistence on rituals after death. They also indicated that death rituals could be done without the body.

It is not that the rituals that provide you salvation… Prayers provide mercy and pardon for the sins committed by the person in their lifetime. You can do all those prayers even without the person’s body. (Religious Scholar Respondent 2, Catholic)

Hindu texts provide ways of performing the ‘shraddha’ (ceremony of reverence) (Sayers 2013) even when a person is alive, or with an article that belonged to the person.

The views of the interviewed scholars of Jainism and Buddhism were that rituals were a personal affair and that individual families adopted these rituals according to cultural influences. This is because the followers of these religions were encouraged to use these rituals simply as a means to contemplate dying and to look at death as the start of a new cycle of life. Therefore, it did not matter how the followers and their families chose to carry out these rituals. From an Islamic perspective, the respective scholar highlighted that the body was central to the death rituals and that no mutilation of the body was permitted. In fact, the purification and body preparation ceremonies were so sacrosanct that body dissection and hence, a donation was not acceptable. ‘Once the person dies the body is placed in a location where nobody can disturb it. A ritual bath is performed very gently that cleans every part of the body. Even while washing, care is taken that you do not actually touch the body. It’s like the body is prepared to meet the lord’ (Religious Scholar Respondent 10, Islam). Clearly, this perspective is a challenge to the propagation of body donation among this religion.

Wider Purpose of Donation

An underlying purpose was to give back to society and be useful even after death—in their words, ‘I’ve lived my life, so I should give back something to the community’ (Donor 12, Hindu male), ‘...it’s something I can do after I’m gone. It’s about doing something for society at the end of the day’ (Donor 2, Christian male).

A contribution that furthered research and science was considered a useful means of giving back and was also connected to the Indian philosophy of ‘daana’ (Donor 10, Hindu female). Those with chronic illnesses, some of which were without cures such as motor neuron disease, were keen that their bodies be used for research. This, they said, was because they wanted scientific progress to be made in the area of those diseases, in order to eventually benefit other people suffering from them. ‘I have motor neuron disease and I wish for my body and brain to be used for research so that many humans can live on with the disease I have’ (Donor 12, Hindu male).

Some of the donors believed that the use of land for burial and wood for cremation was an environmental waste. In pledging their bodies for donation, they thus hoped to offer daana to the Earth itself.

Still, others thought that conducting multiple ceremonies, the building of graves and tombstones were a financial waste and a burden on the family. The purpose of their decision to bequeath their bodies was to make their deaths easier for their families both financially and emotionally. ‘I don’t want my wife to take the pain of actually building my grave, or coming there every month, grieving. I just want her to move on’ (Donor 2, Christian male).

‘Daana’ or selfless giving is an important tenet of Hinduism and ranks third among the Niyamas (virtuous acts) in Hindu philosophical books as well as in other religions like Buddhism and Jainism. ‘Daana’ (used as charity or selfless giving in this context) is also encouraged in Christianity and Islam. The concept of ‘daana’ as a motivation for enrolling in the body donation programme was explained at length by the religious scholars of this study. Daana was not seen as charity or aid, but as a form of service to others. The act of donation was considered ‘to equalise the imbalances in society giving opportunity for the impartial growth of both the giver and the receiver’ (Religious Scholar Respondent 1, Hindu). Across all faiths, the religious scholars said that one was expected to give with a sense of humility. The Christian scholars emphasised the central tenet of sacrificial giving as symbolic of a Christian’s love for the other.

Christianity teaches it quite strongly… Charity is to give; it is to sacrifice. (Religious Scholar Respondent 11, Christian)

There was a higher purpose to donation and receiving a reward, in terms of recognition of their noble deed by others was contrary to their purpose of daana. This also emerged as a significant value of donors who preferred anonymity over recognition. Many of the donors felt that in death, all were made equal. They opined that providing a short write-up of their medical condition would be of greater value to students than indicating their names and backgrounds. Some respondents, nevertheless, were willing to sacrifice their anonymity if it promoted body donation.

Two-way Giving

Although the donation was being made with altruistic motives, it can be seen as a two-way process with commitments on both sides. There were expectations of the medical college and medical students by body donors, centred around respect:

Of the Medical College-

Next of kin wanted the collection of the body after death to be simplified and transport provided. A clearly stated concern and expectation were the respectful disposal of the remains of donors, with specific wishes of some that the remains should be buried, that a small part of the remains be given to the family for the rituals to be performed and for the ashes to be scattered amidst nature. The next of kin found it hard to accept that the body would be used and then discarded. A need for a ceremony or symbolic process was expressed, to enable the family to attain closure, although some felt that to prolong the mourning period was not good for the family.

When asked about possible ways of enhancing the body bequest programme, four of the donors in this study suggested its promotion in public gatherings like festival celebrations, to achieve its social acceptance. While donors understood that their bodies would be used for medical education, they also expressed the desire for some parts (predominantly eyes) to be donated to patients. Many of the religious respondents interviewed said that this would encourage people to donate, as most religions, irrespective of their outlook on body donation, are supportive of organ donation to ‘save a life’.

Of Medical Students-

While the donors in this study did not demand respect from the students, they did feel that respect could be expressed, as ‘appreciation that someone has donated their body, and that maybe one or two students in the entire group who were paying respect would be motivated to take the same decision’ (Donor 2, Christian male) and ‘knowing something about him (the donor), whatever little they can’ (Donor 6, Jain female) would be a sign of respect. Multiple references were made to internalisation of respect to the person behind the body. This expectation of respect was more pronounced among the next of kin of the donors. The next of kin felt primarily that the bodies of their loved ones should be handled and maintained well, with respect. Religious scholars also suggested that people’s apprehensions of lack of respect prevented them from bequeathing their bodies for medical education.

When asked about the inclusion of a prayer service before beginning the dissection of the donated bodies, many of the donors responded positively. It would be a preliminary lesson for medical students to respect cadavers as human beings, which would lay the ground for them to respect their patients in their eventual work as medical professionals. As one donor said, ‘maybe it [the ceremony] would teach students about respecting their patients and seeing them as human beings’ (Donor 8, Christian female).

They wanted the students who learned from their bodies to become good doctors, competent in diagnosis, empathetic and knowledgeable. When asked to provide the students with a message, a donor said, ‘They should become good doctors so they can help patients well. Then, this donation will be for the bigger purpose of effectively healing people in the future…’ (Donor 5, Hindu male) and in the words of another, ‘Make the people who have donated their bodies proud by learning your lessons well. Study and go on an unyielding, undying pursuit of knowledge’ (Donor 11, Parsi male).

These results provide a theoretical construct of interconnected factors influencing body donation—the life of a donor, an overcoming of the conflicts with death and death rituals, daana as a form of service, and the ultimate desire of donors to help develop a respectful, humane doctor (Fig. 1).

Fig. 1.

Diagrammatic representation of the main themes

Discussion

Body donation studies conducted in India (Ballala et al. 2011; Rokade and Gaikawad 2012; Dope et al. 2015; Saha et al. 2015) have interviewed individuals from the general population, who have not pledged their bodies to a donation programme. This study using qualitative in-depth interviews of people who had committed their bodies after death to an anatomy body donor programme therefore provides responses that are more nuanced, personalised and reflective. The results demonstrate that the people in this study have come to terms with death, overcome social constraints and identify with a higher purpose in giving of themselves even after death. They have overcome religious barriers, customs, cultural norms, discomfort with death, mortality and body image in making their decision (Gillman 1999; Golchet et al. 2000; Ajita and Singh 2007). They have given this decision great thought and meaning, thus making voluntary body donation a more ethically acceptable practice than the use of unclaimed bodies in medical colleges (Jones and Whitaker 2012; Jones 2016).

Families, however, often find it difficult to accept the decision of their loved one. The interviews sometimes indicated a communication gap, between donors and their families. Donors appear to be apprehensive, or unable to convey their decision, as it would possibly mean that their next of kin would have to come to terms with their mortality. Counselling family members along with the potential donor to bridge the communication gap between donor and family is critical. This is also important, as the immediate family is responsible for bringing the body to the medical college. The ‘will-form’ only ensures the donor’s registration in the bequest programme of the medical college. In India, the donation cannot be fulfilled if the relatives do not wish to continue with the donation (Government of Karnataka 1957; Mutalik 2015).

Additional factors that deterred body donation, also observed in other studies, were embarrassment at the thought of exposure of the body during dissection (Richardson and Hurwitz 1995; Rokade and Gaikawad 2012) and the fear that the body would not be treated with respect and dignity (Bolt et al. 2010).

In many South Asian religions, death is an important moment of passage since it helps an individual to be free from the cycle of birth and death (Wilson 2003). In India, where death rituals are important across religions, body donation is a sensitive issue, interpreted as going against tradition. A rigid understanding of faith has, in part, undermined body donation in countries like China and Korea (Park et al. 2011; Zhang et al. 2014). The belief that the whole body is required for the death rituals has been challenged by religious scholars in this study and is said to reflect a lack of awareness among people of the theology behind rituals (Ajita and Singh 2007). Creating awareness is important, not just of the existence of credible body donation programmes but also of the religious injunctions related to death and death rituals among all religions. Therefore, the role of religious leaders in educating people about the deeper significance of death rituals and beliefs of the body can help influence body donation. Religion, while conventionally viewed as a deterrent to body donation, can become instrumental in enabling large numbers of body donors as in the Buddhist countries of Thailand and Sri Lanka (Winkelmann and Guldner 2004; Subasinghe and Jones 2015). In addition, religious organisations, civil society and non-governmental organisations can also promote this.

A key motivation of the donors in this study was the need to be of use even after death. This sense of altruism, of ‘giving back’ and being of service to others beyond one’s lifetime, fits into the Indian concept of ‘daana’. Daana in Indian philosophy is a generosity of spirit to give with a sense of modesty and humility. It is also a central ethical premise, as the gift of their bodies enables the training of doctors, of advancing medical knowledge, without seeking fame or monetary gain. The secondary motive of making the process easier for the immediate family can also be considered an expression of daana, as the donor has done it out of sensitivity towards his family. Religious organisations, civil society and non-governmental organisations can also promote this form of deh daana (body donation). Combining organ donation with body donation would also promote bio-daana as a whole. Even Islamic medicine, which globally does not favour body donation (Șehirli et al. 2004) for dissection, supports donating one’s organ, ‘a gift of God’ to a person in need (Rady et al. 2009). This was expected to be done without monetary gain or any type of external pressures (Hassaballah 1996).

Integrating religious ceremonies as well as ceremonies of gratitude and respect grounded in the local cultural and religious beliefs, in medical colleges, the respectful handling of the cadavers (Ghosh 2017) and disposal of the remains after dissection can address the deep-seated concerns of families and society at large (Park et al. 2011; Zhang et al. 2014; Subasinghe and Jones 2015; Pabst et al. 2017). Setting aside a space and time for closure and remembrance for families (Riederer and Bueno-Lopez 2014; Pabst et al. 2017; Pather and Ashwell 2017) is also a valuable suggestion. In Nanjing, medical students pay their respect at commemorative platforms for the donors, during the annual Tomb Sweeping Day festival (Zhang et al. 2014). Medical students undertake the Cadaveric Oath in medical colleges in the UK (Ali et al. 2015) and in India (Sawant et al. 2015; Lala 2016). Students in German-speaking countries conduct Christian religious ceremonies of gratitude (Pabst et al. 2017) while medical students in Basel, Switzerland, have formed a choir group and thank the donors’ family during a gratitude ceremony (Riederer and Bueno-Lopez 2014). These ceremonies address society’s apprehensions about how the body will be treated. They also ensure that medical students inculcate respect and honour ‘the gift’ of a body donor (Park et al. 2011), keeping in mind that donors want medical students to become ‘good doctors’, altruistic and caring towards their patients, as the ultimate fulfilment of the donation of their body.

As an outcome of this study, the medical college housing this body donation programme has begun inviting willing body donors to speak to the first year medical students before they start their Anatomy course. It has also initiated the setting up of an Eternal Grove, a space where students honour and respect the contribution of body donors to their education and for families to know that there is a place for them to visit to mark the eternal gratitude, respect and peace bestowed on their loved ones by the institution.

Dissection is one of the most profound experiences in a medical student’s life (Rizzolo 2002). The ethics of patient care as well as respect and understanding of the fears and aspirations of patients can thus be cultivated at the preliminary stage of a medical student’s education. A deeper understanding of the background and motivations of the donors, as in this study, not only contributes to increased respect for the donor by medical students, but also serves as encouragement for more people to donate their bodies towards this cause. Outreach programmes arranged by Departments of Anatomy can inform the general public about the important purpose of body donation in helping medical science education (Chakraborty et al. 2010; Bolt et al. 2010; Cornwall et al. 2012; Da Rocha et al. 2012), and in the process, society, by training good doctors with the cadaver as their ‘first teacher’ (Lin et al. 2009) and their ‘first patient’ (Talarico 2013).

Involving those who have enrolled in successful body donation programmes such as the ones in this study, as well as religious leaders to address the doubts and fears of the Indian public in terms of the social and religious sanctions may be important to popularise body donations.

Limitations of the Study

The study had a limited sample size and was limited to one successful body donation programme in one medical college, in one city in India. Being a qualitative study, following a non-positivist approach, the results cannot be generalised, even though the sample mirrored the general profile of donors in the programme during the duration of the study. Data collection was stopped once data saturation was reached, and since three pairs of registered donors belonged to the same family unit, data saturation may have been achieved faster due to a concurrence of opinions. Further, the next of kin interviewed based on their availability were all women. While it is possible that this occurred because women are most often the primary caregivers at home, it is not possible to know whether different views would have emerged if the next of kin to be interviewed were men. The religious scholars included in this study were not matched with the body donors included in this study and are not reflective of the diversity of schools of thought that exist within Hinduism or any other religious group in India.

The findings and the limitations of this study lend themselves to the focus of possible future research. These include how medical students view the dissection of cadavers particularly if they are sensitised to the motivations and expectations of body donors, how the philosophical understandings of religion contrast with commonly held beliefs on body donation, how the perceptions of body donors can be used to inform organ donation and blood donation campaigns, and what methods can be evolved to resolve donor-family conflicts that respect the autonomy of the donor while acknowledging the concerns of the family.

Conclusions

The use of unclaimed bodies for dissection has unethical implications, as it is typically exploitative in nature, violates the autonomy of the individual and undermines the value and dignity of human life. This study concludes that voluntary body donation respects the important ethical concepts of personhood, informed consent and dignity. In India, where body donation is low, there is a pressing need to promote this practice in order to increase the ethical sourcing of cadavers for medical education. The challenges in this regard that emerged from this study include convincing the next of kin, who are often uncomfortable with the donor’s decision and people’s misinterpretations of religious injunctions revolving around body donation. It is important that dialogue/counselling involving the next of kin occurs at the time of the bequest. Additionally, religious leaders/scholars can play a significant role in addressing misconceptions, providing theological clarity around rituals and in promoting body donation as ‘deh daana’. This has been seen in the success of voluntary blood donation and organ donation programmes due to the joint efforts of religious scholars, media coverage, participation of celebrities, non-government organisations and Governmental bodies. An impetus to body bequest programmes in India as well as an improvement of existing donation programmes can be achieved by including ceremonies of respect in a medical college, and enhancing public engagement on the issue. The strength of this study is that it showed diverse and dissenting views of body donation, and hence, in a multi-cultural country like India, the ethical position would be to respect these differences and attempt to understand them. Health practitioners and medical students need to be exposed to the socially grounded realities that inform their practice. When medical students internalise what body donors expect of them, i.e. altruism, empathy with patients and becoming ‘good doctors’, it will ensure that the donation was not in vain and that the dead truly teach the living.

Appendix

Funding Information

The Institutional Ethics Committee (IEC) of St. John’s National Academy of Health Sciences (SJNAHS) provided a grant for the conduct of this study.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.