Altruism in death: Attitudes to body and organ donation in Australian students

Abstract

Health education, research, and training rely on the altruistic act of body donation for the supply of cadavers. Organ transplantation and research rely on donated organs. Supply of both is limited, with further restrictions in Australia due to requirements for a next‐of‐kin agreement to donation, irrespective of the deceased's pre‐death consent. Research suggests health workers are less likely to support the donation of their own bodies and/or organs, despite recognizing the public good of donation, and that exposure to gross anatomy teaching may negatively affect support for donation. Attitudes to body and organ donation were examined in Australian students studying anatomy. Support for self‐body donation (26.5%) was much lower than support for self‐organ donation (82.5%). Ten percent of participants would not support the election of a family member or member of the public to donate their body, and just over 4% would not support the election of a family member to donate their organs, with one‐to‐two percent not supporting this election by a member of the public. Exposure to gross anatomy teaching was associated with an increased likelihood of consideration of issues about body and organ donation, whether for self, family, or the public, and registration as an organ donor. Exposure decreased participants' willingness to donate their own body, with those who practiced a religion least likely to support body donation. Gross anatomy courses provide an opportunity to inform future healthcare workers about altruistic donation, albeit with a recognition that religious or cultural beliefs may affect willingness to donate.

INTRODUCTION

Body and organ donation are profoundly valuable post‐mortem altruistic acts. Their value to the community is substantial and enduring. Body donation enables medical education, surgical and other post‐graduate clinical training, and defense, pharmaceutical, road safety, and medical device research, with future healthcare workers benefitting from the use of donated bodies (cadavers) in studies of anatomy and the anatomical sciences (O'Neill, ¹⁹⁹⁶; Roach, ²⁰⁰⁴; Delotte et al., ²⁰⁰⁸; Cornwall & Stringer, ²⁰⁰⁹; Jones & King, ²⁰¹⁷). Organ donation saves lives, with the number of eligible organ transplant recipients greatly exceeding the number of donations each year both in Australia (Donate Life, 2022) and internationally (Arshad et al., 2019).

In Australia, unlike in some other jurisdictions (Riederer, 2016; Habicht et al., ²⁰¹⁸), all cadavers used in education and research are donated. Would‐be donors sign up for their local (university‐based) body donation program prior to death. The consent process includes explicit engagement of next‐of‐kin and family and does not involve remuneration. Likewise, organ donation in Australia operates on an “opt‐in” system with explicit next‐of‐kin consent required at the time of death for a donation to occur, irrespective of the deceased's election to donate prior to death. Little has been reported about the support of the Australian community for body donation. Support for organ donation is high, with surveys reporting consistent levels of 85%–90% of those Australians surveyed in favor of organ donation (Irving et al., 2012, 2014; Sharpe et al., ²⁰¹⁷). However, actual donor registrations are much lower with only one in three Australians on the donor register (Sharpe et al., 2017; Donate Life, ²⁰²²), and the unique and limited circumstances in which organ donation is possible further restrict the number of available organs.

The Australian community is highly multi‐cultural and it is known that both body and organ donation are less common among some ethnic groups (Khanal et al., 2018; Donate Life, ²⁰²²), despite public health campaigns aimed at addressing misconceptions about donation. The reasons for these disparities are complex; notwithstanding the Australian commitment to the exclusive use of donated bodies and organs, for many, the use of cadavers and organ donation are challenging, and ethnicity, beliefs, and experiences may influence responses to their use in education, research, and healthcare. However, the disparity in donation rates has tangible consequences in healthcare and education; students from non‐Caucasian backgrounds who are training as healthcare workers rarely, if ever, encounter donor bodies that reflect their ethnicity or culture. Thus, their capacity to discuss donation with family and friends and/or with peers and colleagues may be hindered (Curtis et al., 2019). Similarly, acute shortages of donated organs from donors of non‐Caucasian ethnicities may delay or compromise the chances of transplantation because of less than ideal tissue and genotype matching (Khanal et al., 2018).

The critical role of health professionals in informing and supporting families about, and through, the donation process has been documented in a number of studies (Williams et al., 2003; Dubois & Anderson, ²⁰⁰⁶; Zambudio et al., ²⁰⁰⁶; Demir et al., ²⁰¹¹; Sellers et al., ²⁰¹⁸). Reluctance to raise the issue of organ donation, particularly with distressed family members, is a significant barrier to donation occurring (Dubois & Anderson, 2006; Potter et al., ²⁰¹⁷). There is also evidence to suggest that donation and discussion of organ donation are more common among individuals who know others who have donated, are recipients of organs, or are on a transplant waiting list (Sung et al., 2008; Phillipson et al., ²⁰¹⁵; Sellers et al., ²⁰¹⁸). A New Zealand study of registered body donors also reported that knowing someone who had donated or registered to donate their body, was a significant factor in the likelihood of being registered as a body donor (Fennell & Jones, 1992).

A study of 6861 potential organ donors in 2012 across 68 Australian hospitals (Pilcher et al., 2015) reported that discussion by health care professionals with family about donation occurred in 98% of donor cases compared to only 16% of non‐donors. It was apparent from this study and others, that successful organ donation was facilitated by knowledge of the wishes of the deceased to participate in organ donation prior to death, the presence of dedicated donation counseling and support staff, and a willingness of all those involved with the care of the patient to discuss donation and its implications (Irving et al., 2014; Neate et al., ²⁰¹⁵; Pilcher et al., ²⁰¹⁵; Marck et al., ²⁰¹⁶).

Health care workers have a critical role in facilitating discussion about body and organ donation, and in advocating for their importance in medical care, education, and research (Rikker & White, 1995; Ghorbani et al., ²⁰¹¹; Irving et al., ²⁰¹²; Keel et al., ²⁰¹⁹; Robert et al., ²⁰²¹). Their capacity to undertake effective advocacy for donation, and to approach families with confidence and sensitivity, is in no small part dependent upon them having accurate, up‐to‐date, and nuanced knowledge about body and organ donation programs and processes (Hyde & Chambers, 2014; Marck et al., ²⁰¹⁶; Keel et al., ²⁰¹⁹). Understanding the ethnic, cultural, and religious context in which such attitudes are formed and held is also important.

Despite continued debate about the need for gross anatomical dissection in medical education (Winkelman, 2007; Ghosh, ^2017a), international research consistently reports that exposure of students to gross anatomical dissection, whether through active dissection or instruction using prosected specimens, is beneficial (Pawlina & Lachman, 2004; Winkelman, ²⁰⁰⁷; Sugand et al., ²⁰¹⁰; Estai & Bunt, ²⁰¹⁶; Ghosh, ^2017a,b). Students themselves value the experience of cadaveric dissection and consider it integral to their learning (Quince et al., 2011; Mwachaka, et al., ²⁰¹⁶; Flack & Nicholson, ²⁰¹⁷; Alamneh, ²⁰²¹; Asante et al., ²⁰²¹; Bahşi et al., ²⁰²¹), despite their reservations or anxiety about their first encounter with the dead body, or other unpleasant aspects of dissection (Quince et al., 2011; Dissabandra et al., ²⁰¹⁵; Allison et al., ²⁰²¹). Exposure to cadavers and anatomical dissection is also regarded as an important professional development milestone for students, assisting them to develop broader professional competencies including skills in self‐reflection about death and grieving, managing challenging and distressing situations, teamwork, and communication (Pawlina et al., 2006; Drake et al., ²⁰⁰⁹; Böckers et al., ²⁰¹⁰; Johnson et al., ²⁰¹²; Ghosh, ^2017a,b; Allison et al., ²⁰²¹). It also provides an opportunity for students to consider the altruistic act of donation and to develop an understanding of the legal and ethical framework in which donation occurs, areas where medical student knowledge has been reported to be deficient (Bardell et al., 2003; Essman & Thornton, ²⁰⁰⁶; Goz et al., ²⁰⁰⁶; Ghahovac et al., ²⁰⁰⁷; Tontus et al., ²⁰¹¹; Ciliberti et al., ²⁰¹⁸; Robert et al., ²⁰²¹). These skills are integral to their capacity to treat patients with a terminal illness, communicate with grieving families, and initiate and manage conversations about body, organ, and other tissue donation.

However, exposure to gross anatomical dissection has been suggested as a contributing factor in the development of negative attitudes to the use of the body after death, including for body donation, organ transplantation, and education and research using donated human tissue (Cahill & Ettarh, 2008, 2011; Alexander et al., ²⁰¹⁴; Galic et al., ²⁰¹⁶; Viljoen & Stephens, ²⁰²¹). Across many countries, medical and health sciences students exposed to gross anatomical dissection reported diminished support for body donation, with students differentiating between support for the public to donate (recognizing the importance of the use of donated bodies in medical education) and reluctance to support donation by family or themselves. Cahill and Ettarh (2011) reported a negative effect after completion of courses in anatomical dissection on a subgroup of students' willingness to donate their own organs or support their families to donate organs. Other international studies (Fennell & Jones, 1992; McClea & Stringer, ²⁰¹⁰; Cornwall et al., ²⁰¹²; Anyanwu & Obikili, ²⁰¹²; Rokade & Gaikawad, ²⁰¹²; Anyanwu et al., ²⁰¹⁴; Green et al., ²⁰¹⁴; Galic et al., ²⁰¹⁶; Dagcioglu et al., ²⁰²¹; Viljoen & Stephens, ²⁰²¹) have also reported that medical students and health professionals, including doctors, express less willingness to donate their bodies, despite advocating for the public to do so, and that support for organ donation consistently exceeds support for body donation.

Student attitudes to body donation have not been found to be related to education level (Viljoen & Stephens, 2021), but have been reported to be related to the length of exposure to anatomical dissection or gross anatomy (Alexander et al., 2014; Galic et al., ²⁰¹⁶; Vijoen & Stephens, 2021). Students' and health professionals' personal or religious beliefs have also been identified as significant factors mediating their support for body and organ donation (Galic et al., 2016; De Gama et al., ²⁰¹⁸; Dagcioglu et al., ²⁰²¹; Naidoo et al., ²⁰²¹) with those who identified as atheists or agnostic more likely to support self‐body donation compared to their peers who stated that they practiced a religion (Galic et al., 2016; Naidoo et al., ²⁰²¹). Ignorance of body and organ donation processes has been cited as a significant barrier to donation both in Australia (Neate et al., 2015; Marck et al., ²⁰¹⁶) and internationally (Hu & Hang, 2015; Mwachaka et al., ²⁰¹⁶; Dagcioglu et al., ²⁰²¹).

Undertaking studies of anatomy is near‐universal for healthcare professionals in Australia and thus may provide an opportunity to introduce, inform and educate students and future healthcare workers about the legal and ethical framework in which both body and organ donation occurs. The multi‐cultural nature of Australian society and thus the health workforce, and the people whose health care they will deliver would benefit from broadening knowledge about, and support for, altruistic human tissue donation across all cultural, ethnic, and religious groups. However, it is critical that the attitudes and beliefs of students from all backgrounds about human tissue donation and its use are sensitively considered and accommodated in any programs of instruction aimed at improving knowledge and understanding of donation. This is an area where knowledge is still scant.

This study, therefore, seeks to explore attitudes to body and organ donation of students who undertake courses in anatomical sciences at The University of Sydney. This student cohort encompasses local and international students from many different countries and cultural backgrounds. Drawing on the existing literature, the authors hypothesize that continued and more intense exposure to gross anatomy will be associated with more negative views about body donation than occurs with shorter and less intense exposure. It was also hypothesized that students will be more willing to support body and organ donation by the public than they are to support donation of their own bodies and organs or those of their family members, and that their ethnicity and cultural beliefs will be reflected in their reasons for, or against, supporting donation.

MATERIALS AND METHODS

The study was conducted at The University of Sydney with participants recruited from enrolled students. The research protocol was reviewed and received ethics approval from The University of Sydney Human Research Ethics Committee, protocol approval number 2017/917.

Survey instrument

A thirty‐one item questionnaire was developed. The questionnaire had three sections: (1) demographic information including age, identified gender (if any), language spoken at home, practice of religion, home country, previous anatomy study; (2) attitudes to body donation, for themselves, their family and the public; (3) attitudes to organ donation for themselves, their family and the public. All questions were optional.

The questionnaire was piloted on a small group (26 participants) of undergraduate and postgraduate students and academics. Question wording and options were adjusted to reflect feedback. Cronbach's alpha was calculated and was found to be 0.849 indicating a good level of reliability. The questionnaire is available as Supporting Information.

Support for body donation was examined via answers to three questions: (1) Would you be willing to donate your body to The University of Sydney for research and education?, (2) Would you support a member of your family to donate their body?, and (3) Would you support a member of the public to donate their body?

Support for organ donation was examined via answers to three questions: (1) Would you donate your own organs for transplantation?, (2) Would you support a family member to donate their organs for transplantation?, and (3) Would you support a member of the public to donate their organs for transplantation?

For both body and organ donation questions, participants were able to select either “Yes,” “No,” and “Have not thought about it” in response to all questions.

Participants were asked to choose from a list of six possible reasons to support body donation and a list of 14 reasons against supporting it. There were eight reasons to select from to support organ donation, and nine reasons against supporting it. Participants were able to make multiple choices from each list, provide a free text response (other reason), and indicate reasons both for and against donation.

A printed paper version of the questionnaire was administered to students recruited through the (then) Discipline of Anatomy and Histology at the University of Sydney. An online version of the questionnaire, hosted on the LimeSurvey (GmbH, v2 2006, Hamburg: Germany) platform, was administered to Mathematics students.

Participant recruitment

Recruitment of participants to complete the paper‐based questionnaire occurred in 2018 and 2019, and the online survey in 2019. Participation was voluntary. Undergraduate students comprised four groups—Anatomy Experience; Health Sciences; Medical Sciences; Mathematics. Students who were completing a unit of study in the Discipline of Anatomy and Histology (the first three groups) were approached in a timetabled class. Mathematics students were first‐year students enrolled in a mathematics unit via the School of Mathematics and Statistics. They were emailed an explanatory invitation written by the authors to participate in the study by the first‐year coordinator. The participant information statement and survey link were attached. A reminder email was sent 2 weeks later and then a week before the survey link closed. The online version of the questionnaire remained open for 6 weeks.

Postgraduate students/trainees were approached at the commencement of their first gross anatomy laboratory session. These students included Medical and Dentistryl students, and Postgraduate trainees undertaking a Master's degree. Questionnaire responses were collated across all courses and both years.

Cohort groups for analyses

In total, 2056 participants were included in the analysis. These comprised 1923 students who completed paper questionnaires across 2018 (929) and 2019 (994), and 133 Mathematics students. The largest group of respondents were undergraduate students (N = 1447; 70.4%). Response rates (calculated using class enrolment numbers rather than attendance numbers) averaged 58% for the paper survey, and 12.2% for the online survey.

Students were grouped into five cohorts, on the basis of their exposure to gross anatomical dissection and previous anatomy study/experience:

1. Mathematics (n = 133) and Anatomy Experience (n = 172) students: (total N = 305), a minority of whom (14.8%) reported having studied anatomy previously, with more than half stating this occurred in high school (in biology and physical education subjects), and whose current exposure was limited at most to one elective, two‐hour laboratory Anatomy Experience class using plastic models and specimens of main organs. The Anatomy Experience course was offered to first‐year students in Nursing, Science, and Arts. The majority of the students electing to take the course were from Nursing.

2. Health Sciences students (N = 279), comprise those undertaking courses in Sports and Exercise Science; Physiotherapy; Speech Pathology; Occupational Therapy; and Osteology, of whom 37.3% reported having studied anatomy previously, predominantly at the tertiary level. Anatomy lectures and laboratory classes are core course requirements and include guided instruction in organ systems related to their degree specialty, for example, the limb musculature for physiotherapy students.

3. Medical Sciences students (N = 863), comprise those students who have chosen to complete courses in anatomy, and who are likely to be pursuing majors in anatomy and/or neuroscience, of whom 36.7% had studied anatomy previously, predominantly at tertiary level. Their course requirements included lectures and laboratories focused on the self‐guided discovery of anatomical structures and their relationship to organ systems and human physiology.

4. Postgraduate Medical and Dentistry students (N = 555), of whom 68.3% reported having studied anatomy previously, mostly at Australian and overseas universities as part of their undergraduate education. These students' courses include two years of compulsory system‐based anatomical studies in lectures and laboratories, with a strong focus on self‐guided learning of anatomical structures, their relationship to normal and disease states in humans, and clinical reasoning.

5. Postgraduate trainees (N = 54), 89.1% of whom had previously studied anatomy at university in Australia/overseas, and who had enrolled in intensive courses in gross anatomical dissection as a compulsory component of their professional qualifications in surgery, or in intensive courses using prosected cadaveric specimens as a compulsory component of their professional qualifications in critical care. The majority of these students were medical graduates.

Statistical analysis

Survey responses were compiled for analysis using SPSS statistical package, version 26 (IBM Corp., Armonk, NY). Descriptive statistics (percentages) were used to examine the proportions of participants who were supportive of body/organ donation for themselves, their family, and the public. As all variables investigated were categorical, except for age, cross‐tab chi‐squared statistics (χ ²) were used to examine differences in demographic characteristics, exposure to anatomical dissection, and attitudes to body and organ donation. A significance level of α < 0.001 was adopted to account for the large sample correlations and to ensure significant relationships were identified conservatively.

RESULTS

Cohort characteristics

The demographic characteristics of the cohort are described in Table 1.

TABLE 1.

Participant demographic characteristics for the whole group and five cohort sub‐groups

Participant group	Whole cohort	Mathematics and Anatomy Experience	Health Sciences	Medical Sciences	Postgraduate Medicine and Dentistry	Postgraduate trainees
Number, n (%N)	2056 (100)	305 (14.8)	279 (13.6)	863 (42.0)	555 (27.0)	54 (2.6)
Age
Mean (median)	21.3 (20.0)	19.4 (18.0)	20.2 (19.0)	20.0 (20.0)	24.2 (24.0)	28.7 (28.0)
Standard deviation	±3.8	±3.9	±4.3	±2.2	±3.0	±3.6
Range (Min–Max)	(17–64)	(17–64)	(17–50)	(17–40)	(17–43)	(23–38)
Identified gender a
Identified as female? n (%N)	1280 (62.3)	198 (64.9)	225 (80.6)	548 (63.5)	291 (52.4)	18 (33.3)
Identified as male? n (%N)	691 (33.6)	94 (30.8)	41 (14.7)	269 (31.2)	251 (45.2)	36. (66.7)
Speak English at home? Yes, n (%N)	977 (47.6)	154 (50.5)	118 (42.3)	354 (41.1)	318 (57.4)	33 (61.1)
Practice a religion at home? Yes, n (%N)	756 (37.1)	104 (34.2)	151 (54.7)	321 (37.6)	167 (30.3)	13 (24.1)
Local student, Yes, n (%N)	1511 (73.6)	240 (78.7)	225 (80.6)	612 (71.2)	382 (69.0)	52 (96.3)
Studied anatomy previously, Yes, N (%N)	894 (43.6)	45 (14.8)	104 (37.3)	317 (36.9)	379 (68.4)	49 (90.7)
Where studied anatomy previously? b
At University, Yes, n (%N)	789 (88.2)	21 (46.7)	89 (85.6)	278 (87.7)	360 (95.0)	49 (100)
At School, Yes, n (%N)	64 (7.2)	24 (53.3)	11 (10.6)	29 (9.1)	1 (0.3)	0 (0)

Note: Participant numbers and demographic information for the whole cohort (N = 2056), and five cohort groups. Cohort numbers are expressed as total (n) and as (% of whole cohort [N]). Identified gender, language spoken at home, religious practice, local student status, and previous anatomy exposure are expressed as a percentage of the number (n) of each sub‐cohort group who provided this information. Number of students in Mathematics subgroup (n = 133) and Anatomy Experience subgroup (n = 172).

^a Not all students reported their identified gender.

^b Not all students specified where they had studied anatomy previously.

The majority of the cohort comprised local students, and just over a quarter were international students. Approximately 13% of these students were from Asian countries, predominantly China, and 6.5% were North American (predominantly Canadian). Two of the local students identified as Indigenous. Of the students who spoke a language besides English at home, 30% spoke an Asian language (predominantly Chinese, Mandarin, and/or Cantonese), and 5% each spoke another European language or a Sub‐Continental language (predominantly Hindi). Nearly 20% of the local students spoke an Asian language at home, as did 17% of the North American students.

The most commonly practiced religion was Christianity (65%), then Buddhism (12%), with 10% identifying as followers of Islam. Thirty percent of local students who reported practicing a religion identified as Christian, less than 4% as Muslims and less than 3% as Buddhists. The majority of Muslim students came from the Middle East (56%) and the Sub‐Continent (22%). Seventy percent of those students who practiced Buddhism came from Asian countries and 11% from the Sub‐Continent.

Body donation

Support for body donation and the percentage of participants who self‐reported registration as body donor is summarized in Table 2.

TABLE 2.

Attitudes to body donation

Cohorts		Willing to donate own body?				Would support a family member to donate body?				Would support a member of the public to donate body?				Registered as a body donor?
		Yes	No	Not thought about it	p‐value	Yes	No	Not thought about it	p‐value	Yes	No	Not thought about it	p‐value	No	Yes	p‐value
Whole cohort, N (%)	N c = 2056 (100)	543 (26.5)	629 (30.7)	878 (42.8)		1479 (72.3)	210 (10.2)	358 (17.5)		1769 (86.3)	53 (2.6)	227 (11.1)		1965 (96.7)	67 (3.3)
Previous anatomy experience, n (%)	n c = 894 (100)	240 (26.9)	338 (37.8)	316 (35.3)	<0.0001a	677 (75.8)	88 (9.9)	128 (14.3)	<0.002	805 (90.0)	15 (1.7)	74 (8.3)	<0.0001a	860 (96.5)	31 (3.5)	0.685
No previous anatomy experience, n (%)	n c = 1156 (100)	303 (26.2)	291 (25.2)	562 (48.6)		802 (69.5)	122 (10.6)	230 (19.9)		964 (83.5)	38 (3.3)	153 (13.2)		1105 (96.8)	36 (3.2)
Mathematics and Anatomy Experience, n (%)	n c = 305 (100)	87 (28.5)	72 (23.6)	146 (47.9)	<0.0001b	214 (70.2)	30 (9.8)	61 (20.0)	<0.002	256 (84.0)	15 (4.9)	34 (11.1)	<0.0001b	289 (95.7)	13 (4.3)	0.071
Health Sciences, n (%)	n c = 279 (100)	57 (20.4)	95 (34.1)	127 (45.5)		189 (68.2)	28 (10.1)	60 (21.7)		227 (81.7)	11 (3.9)	40 (14.4)		269 (97.1)	8 (2.9)
Medical Sciences, n (%)	n c = 863 (100)	243 (28.2)	225 (26.1)	395 (45.8)		599 (69.5)	100 (11.6)	163 (18.9)		717 (83.1)	26 (3.0)	120 (13.9)		832 (97.8)	19 (2.2)
Postgraduate Medicine and Dentistry, n (%)	n c = 555 (100)	139 (25.0)	224 (40.4)	192 (34.6)		440 (79.3)	49 (8.8)	66 (11.9)		522 (94.0)	1 (0.2)	32 (5.8)		528 (95.1)	27 (4.9)
Postgraduate trainees, n (%)	n c = 54 (100)	19 (35.2)	13 (24.1)	22 (40.7)		42 (77.8)	3 (5.5)	9 (16.7)		52 (96.3)	0 (0)	2 (3.7)		52 (98.1)	1 (1.9)

Note: Participant support for body donation comparing those with previous anatomy experience and those without, and comparing across the five cohort groups. Responses are expressed as a percentage (%) of the total number N (whole cohort) or n (cohort sub‐groups). Cross‐tabs chi‐square analysis shows significant differences when comparing those with previous anatomy exposure and those without (^a p < 0.0001), and across the across the five cohort sub‐groups (^b p < 0.0001), for willingness to donate their own body or to support the public to donate their body. No statistical differences were observed in the percentage of those registered to donate their bodies, or in relation to supporting family members to donate body when comparing all cohort groups and those with/without previous anatomy experience. ^c N and/or n may sum to less than the group N and/or n as some participants did not answer the question.

Support for self‐donation of bodies, across all cohort groups, was low with higher support for a family member or member of the public electing to donate their body. Medical and dentistry students were the most likely to be unwilling to donate their own body. Previous exposure to anatomy was associated with reduced support for self‐donation (p < 0.0001) and with an increased likelihood that participants had thought about body donation for themselves, their family, and the public. This effect was particularly striking in relation to support for the public to donate their bodies: the majority of postgraduate students and trainees had thought about the question, and none of the postgraduate trainees responded negatively to supporting the public to donate their body, with only one postgraduate medical/dentistry student indicating they would not support such an election (all comparisons significant at p < 0.0001). There were no differences across any of the cohort groups in their willingness to support a family member to donate their body.

Religious practice was found to have quite substantial effects on student support for body donation. Support for self‐donation of the body was lowest in those students who practiced a religion at home, with 38.5% of students who practiced a religion not supporting self‐donation compared to 26.0% of non‐practicing participants (p < 0.0005). Just over 40% of both groups had not thought about this issue. More than three‐quarters (76%) of participants who did not practice a religion at home would support a family member to donate their body, whereas only two‐thirds (66.6%) of those who practiced a religion would. The religious‐practicing students were more likely to answer “No” to giving such support (13.1 compared to 8.4% for non‐practicing students) and more likely not to have thought about it (p < 0.0005). Religious practice did not, however, affect support for a member of the public electing to donate their body. Local students (29%) were also more likely than international students (19.2%) to support self‐donation of the body (p < 0.0005) and donation by a family member (77.5 local students versus 57.8% international students; p < 0.0005). Support for public donation of a body was much higher in local students (91.1%) when compared to international students (73%; p < 0.0001). Local students were approximately three times more likely to have thought about body donation for themselves, their family members, and the public (p < 0.0001).

Registration as a body donor

Few participants reported being registered to donate their body—67 in total, 43 of whom identified as local students. The accuracy of self‐reported registration for these participants was questionable as more than half nominated registration via the National Organ Donor Registry (which is not possible) and a further quarter could not recall where they registered as a body donor. Only one local student nominated a body donor program. Of the 24 international students, approximately half were North American, predominantly Canadian, who nominated established province‐related programs. Of the remaining international students, Singaporean students nominated their local legislation (Human Organ Transplant Act [HOTA], 2012), and its embedded capacity to make an election to donate your body rather than be included in the automatic organ donation program on death through the companion Medical (Therapy, Education and Research Act (MERTA) opt‐in scheme. The self‐reports of registration as a body donor by international students appear to be more reliable than those of local students.

Reasons to support body donation

Just over two‐thirds (67.8%) of the participants provided reasons for why they would donate their bodies (Figure 1). Neither age nor identified gender was related to the reasons chosen to support body donation. Participants from English‐speaking backgrounds (46%) were more likely than their non‐English‐speaking peers (35.2%) to choose the reason “your body has no value once you are dead” (p < 0.0005). Participants who stated that they practiced a religion at home were almost half as likely (25.3%) as their non‐practicing peers (48%) to choose this reason for unwillingness to donate their body (p < 0.0005). Participants with previous anatomy exposure (80.5%) were more likely to select “education of future students” as a reason to support body donation than those without such exposure (71.1%; p < 0.0005) and this reason was also selected more often by postgraduate students and trainees (p < 0.0005) when comparing responses across the cohorts.

FIGURE 1.

Reasons for willingness to donate body selected by participants from the whole cohort, and by those in each of the five cohort groups, who answered the question. Responses are expressed as a percentage (%) of the total number N = 1388 (whole cohort) or n (cohort sub‐groups). Cross‐tab chi‐square analysis shows significant differences at ^a p < 0.0001 in reasons selected when comparing across the cohort sub‐groups

Reasons not to support body donation

Fifty‐two percent of the study cohort (1076) chose reasons as to why they would not support body donation (Figure 2). The most commonly cited “other” reason was the wish to donate their body for organ transplantation, nominated most often by postgraduate students and trainees, indicating their greater awareness that body donation generally precludes organ donation (the brain sometimes being an exception).

FIGURE 2.

Reasons for unwillingness to donate body selected by participants from the whole cohort, and by those in each of the five cohort groups, who answered the question. Responses are expressed as a percentage (%) of the total number N = 1076 (whole cohort) or n (cohort sub‐groups). Cross‐tab chi‐square analysis shows significant differences at ^a p < 0.0001 and ^b p < 0.001 in reasons selected when comparing across the cohort sub‐groups

Neither age nor identified gender were found to be associated with reasons for unwillingness to support body donation. Approximately three times as many participants who spoke another language at home (11.4%) chose “my religion doesn't permit” as a reason compared to those who were English‐speaking (4.3%; p < 0.0005), although overall this was not a common reason selected by participants. Thirty percent of non‐English‐speaking background participants chose “my family is not comfortable with it” as a reason for unwillingness to donate, compared to 10.1% of participants from an English‐speaking background (p < 0.0005). English‐speaking participants were more likely to choose “discomfort with the concept” (62.5%), than non‐English background students (46.8%; p < 0.0005), and “I don't want students like me using my body” (41.8 English‐speaking, 25.5% non‐English background; p < 0.0005).

Participants who stated that they practiced a religion at home were much more likely (17%) to choose “my religion does not permit it” for unwillingness to donate their bodies, than those who did not (1.2%; p < 0.0005), and also to nominate “personal beliefs” (32.2 compared to 19.6%; p < 0.0005). These participants also nominated “discomfort with the concept” (59 compared to 48.3%; p < 0.0005), and “I don't want to contemplate my own death” (19.1 compared to 10.2%; p < 0.0005) more frequently than their non‐practicing peers. Twice as many local (16.7%) as international students (8.1%) nominated “I do not want to contemplate my own death” (p < 0.0005).

Participants with no previous anatomy study were more likely to choose “they did not know enough to make a decision” (38.8%), than participants with previous anatomy exposure (25.6%; p < 0.0005). More participants who had studied anatomy previously also nominated “other” and a wish to donate for organ transplantation as a reason not to donate their body (p < 0.0005). Together these findings suggest that exposure to anatomical sciences provides opportunities for students to become more informed about donation.

Organ donation

Table 3 presents the responses to each of the three questions about organ donation for the whole cohort and compares those with previous anatomy experience and those without. It also presents the proportion of participants who self‐reported registration as an organ donor. Students with previous anatomy experience were more likely to support organ donation for themselves, their family, and the public (p < 0.0001). In contrast, students with no previous anatomy experience were approximately twice as likely to indicate they “have not thought about it” in answer to all three questions. Older students were more likely to support the self‐donation of their organs for transplantation and to have thought about the issue (p < 0.0005).

TABLE 3.

Attitudes to organ donation

Cohorts		Would donate own organs for transplantation?				Would support family member to donate organs for transplantation?				Would support a member of the public to donate organs for transplantation?				Registered as an organ donor?
		Yes	No	Not thought about it	p‐value	Yes	No	Not thought about it	p‐value	Yes	No	Not thought about it	p‐value	No	Yes	p‐value
Whole cohort, N (%)	N c = 2018 (100)	1661 (82.5)	104 (5.2)	248 (12.3)		1712 (85.1)	85 (4.2)	215 (10.7)		1814 (90.2)	36 (1.8)	162 (8.0)		1556 (78.0)	438 (22.0)
Previous anatomy experience, n (%)	n c = 880 (100)	770 (87.5)	40 (4.5)	70 (8.0)	<0.0001a	791 (90.1)	31 (3.5)	56 (6.4)	<0.0001a	824 (93.7)	10 (1.1)	45 (5.1)	<0.0001a	602 (69.0)	270 (31.0)	<0.0001a
No previous anatomy experience, n (%)	n c = 1133 (100)	891 (78.7)	64 (5.6)	178 (15.7)		921 (81.2)	54 (4.8)	158 (14.0)		990 (87.4)	26 (2.3)	117 (10.3)		954 (85.0)	168 (15.0)
Mathematics and Anatomy Experience, n (%)	n c = 295 (100)	231 (78.3)	16 (5.4)	48 (16.3)	<0.0001b	239 (81.0)	16 (5.4)	40 (13.6)	<0.0001b	264 (89.5)	5 (1.7)	26 (8.8)	<0.0001b	254 (86.4)	40 (13.6)	<0.0001b
Health Sciences, n (%)	n c = 275 (100)	206 (74.9)	22 (8.0)	47 (17.1)		224 (81.5)	12 (4.4)	39 (14.1)		236 (86.1)	8 (2.9)	30 (11.0)		237 (87.8)	33 (12.2)
Medical Sciences, n (%)	n c = 848 (100)	680 (80.2)	49 (5.8)	119 (14.0)		686 (81.0)	48 (5.7)	113 (13.3)		735 (86.7)	21 (2.5)	92 (10.8)		741 (88.3)	98 (11.7)
Postgraduate Medicine and Dentistry, n (%)	n c = 548 (100)	499 (91.1)	15 (2.7)	34 (6.2)		516 (94.2)	9 (1.6)	23 (4.2)		532 (97.1)	2 (0.4)	14 (2.5)		307 (56.2)	239 (43.8)
Postgraduate trainees, n (%)	n c = 52 (100)	49 (94.2)	2 (3.8)	1 (2.0)		51 (98.1)	0 (0)	1 (1.9)		52 (100)	0 (0)	0 (0)		21 (42.0)	29 (58.0)

Note: Participant support for organ donation comparing those with previous anatomy experience and those without, and comparing across the five cohort groups. Responses are expressed as a percentage (%) of the total number N (whole cohort) or n (cohort sub‐groups). Cross‐tabs chi‐square analysis shows significant differences when comparing those with previous anatomy exposure and those without (^a p < 0.0001), and across the across the five cohort sub‐groups (^b p < 0.0001#). ^c N and/or n may sum to less than the group N and/or n as some participants did not answer the question.

English‐speaking and local students were more likely to support organ donation for themselves, their family, and the public than their non‐English‐speaking and international counterparts. Their support for self‐donation was almost 90%, and for family and public donation of organs for transplantation more than 95%. This difference in support for organ donation by English‐speaking participants compared to their non‐English‐speaking peers was substantial; 15% greater for self‐donation; 18% greater for family donation; 12% greater for public donation of organs (p < 0.0005 for all three comparisons).

Students who practiced a religion were less likely (76.0%) to support self‐organ donation for transplantation compared to non‐practicing participants (86.3%; p < 0.0005). There were no differences between participants who practiced a religion and those who did not with regard to support for family or public donation of organs for transplantation.

Registration as an organ donor

Self‐reported registration as an organ donor was higher across all groups compared to registration as a body donor. However, the postgraduate students and trainees were more likely to report having registered as organ donors, with 58% of the postgraduate trainees reporting being registered organ donors, and 43.8% of postgraduate medical and dentistry students, compared to 11%–15% of the undergraduate participants (p < 0.0001). Students with previous anatomy exposure were more than twice as likely to be registered as organ donors (31%) than those without such experience (15%; p < 0.0001).

Reasons to support organ donation

The majority of the study cohort (86.4%) selected one or more reasons why they would support organ donation (Figure 3). A smaller proportion of the postgraduate trainees compared to the other cohort groups chose “medical research” and a greater proportion chose “a good idea” (p < 0.0001 in both cases), suggesting a greater awareness in this group of the value of organ transplantation.

FIGURE 3.

Reasons for willingness to support organ donation selected by participants from the whole cohort, and by those in each of the five cohort groups, who answered the question. Responses are expressed as a percentage (%) of the total number N = 1776 (whole cohort) or n (cohort sub‐groups). Cross‐tab chi‐square analysis shows significant differences at ^a p < 0.0001 in reasons selected when comparing across the cohort sub‐groups

There were neither age nor identified gender‐related differences in the reasons nominated for supporting organ donation. Students who did not speak English at home were less likely (39.6%) to choose “your organs have no value once you are dead” than their English‐speaking peers (56.9%; p < 0.0005). In contrast, English‐speaking students were more likely to select “I hope if I need an organ transplant, someone will donate for me” and “it is a good idea” (77.6 and 57.6%, respectively), compared to those who were from non‐English‐speaking backgrounds (58.3 and 41.0% respectively; p < 0.0005 for both comparisons), suggesting a distinct difference between how these two groups regarded organ transplantation.

Local students were more likely to express a belief (50.9%) that “your organs have no value once you are dead” than international students (40.6%; p < 0.0005), and that it “was a good idea” (52.3 compared to 40.8% for international students; p < 0.0005). Local students were also more likely (73%) to express the “hope that if I need an organ transplant someone will donate for me” than international students (53.6%; p < 0.0005), again suggesting there is an interplay between cultural and societal norms, including beliefs about the value of organs, altruistic donation, and reciprocity.

Participants who identified as practicing a religion at home were less likely (35.2%) to nominate their “organs having no value once you are dead” as a reason to donate them compared to those who were non‐religious (55.2%; p < 0.0005), and also less likely to nominate organ donation as a good idea (41.8 compared to 53.4% for non‐religious students; p < 0.0005).

Reasons not to support organ donation

Less than a quarter of the cohort (n = 439) answered this question, reflecting the generally higher support for organ donation, and a lower level of ambivalence about motivations to donate or not, in comparison to attitudes to body donation (Figure 4).

FIGURE 4.

Reasons for unwillingness to support organ donation selected by participants from the whole cohort, and by those in each of the five cohort groups, who answered the question. Responses are expressed as a percentage (%) of the total number N = 439 (whole cohort) or n (cohort sub‐groups). Cross‐tab chi‐square analyses showed no significant differences when comparing reasons selected across the cohort sub‐groups

There were no statistically significant differences in the reasons selected for unwillingness to support organ donation associated with age, identified gender, previous anatomy exposure, or across the five cohort groups.

Approximately one‐fifth (19.1%) of the students who practiced a religion and who answered this question, nominated their religious beliefs as a barrier to donation compared to 2.0% of those who did not practice a religion (p < 0.0005). Half of this group also nominated “discomfort with the concept” (50%) compared to 29.4% of their non‐religion‐practicing peers (p < 0.0005).

Comparison of support for body and organ donation

Support for body donation was much lower than support for organ donation (26.5 versus 82.3%) across the whole cohort. However, there was a very high level of support for the public to donate their body (86.3%), especially in comparison to the unwillingness of all participants to donate their own body. While a similar proportion of the whole cohort supported the public to donate their organs (84.2%) as supported the public to donate their body, the disparity between support for own/family donation compared to support for public donation was much greater for body donation compared to organ donation. The difference was also most marked for those students who had undertaken previous anatomy study, who were least likely to indicate they would donate their own body, and the most likely to donate their own organs. Students who supported self‐, family‐, and public donation of the body were also more strongly in favor of organ donation, for themselves (p < 0.0001), their family (p < 0.0001), and the public (p < 0.0001). Those students who answered affirmatively to both questions were also the most likely to have thought about their attitudes to donation, whether it was body or organ donation, and whether for themselves, their family, or the public.

Support for self‐donation of organs (p < 0.00001), and the likelihood of registration as a body donor (p < 0.0001), or as an organ donor (p < 0.00001) increased with age. Otherwise, age was not found to be associated with differences in attitudes to body and organ donation.

DISCUSSION

This study reports a relationship between exposure to anatomical examination using cadaveric tissue, and support for self‐, family‐, and public‐donation of bodies and organs. Previous anatomy exposure and increasing exposure to gross anatomy, are associated with more decisive views (positive and negative) about supporting body and organ donation, strongly stimulate consideration of these issues, and increase the likelihood of registration as an organ donor. Previous anatomy exposure, however, appears to diminish support for self‐body donation, while increasing support for public donation, suggesting that students who undertaken studies in anatomy value the opportunity and thus the altruistic gift of donation, but also show reluctance to donate themselves.

Public good and personal decisions

The findings of this study suggest that participation in anatomical studies using donated human tissues prompts students to think about their own feelings and attitudes to donation, and invokes consideration of whether they would support the wishes of their family and the public to donate. In making these decisions, they are required to balance their own personal feelings, and imagined responses to the loss of a family member, against the clear benefit of the donation.

This study suggests that students were capable of, and inclined to, delineate between the public good that donation represents, and recognition of their feelings in the situation where the possibility of donation arises. The dichotomy between supporting body donation overall but not being prepared to donate themselves, or to support donation for family members, suggest a separation of attitudes with regard to the value of anatomical education and the altruistic act of donation. Other studies have also reported this separation (Cahill & Ettarh, 2008, 2011; Galic et al., ²⁰¹⁶). Further, the lower level of support for family member body donation compared to organ donation suggests that participants experienced ambivalence in balancing their support for (and benefit from) the use of donated bodies from the public, with their own reluctance to donate or to have family members donate. For participants of diverse religious, cultural, and ethnic backgrounds, this ambivalence and tension may be particularly challenging, but that should be a driver rather than a barrier to engaging with these students (in anatomy class) to assist them in developing and defining their views about donation generally, and the use of donated tissue more specifically.

Participants who were inclined against donation or ambivalent about it, and who thus nominated both reasons for and against donation, also felt that they had insufficient information to make decisions about donation of their body or their organs. These participants were more likely to state that they also felt discomfort with the concept, and for some, discomfort occurred irrespective of their support for donation. This was more apparent in relation to body donation, but a small but significant proportion of the cohort articulated reasons both for and against organ donation, demonstrating insight into the complexity of these issues at a personal level. These findings affirm the lack of knowledge and competence medical and health sciences students feel when asked to consider issues of human tissue use and donation, be it for education, research, or clinical treatment. The students also preferred the word “discomfort” over “distaste” in relation to both body and organ donation, suggesting that the emotional response is not so much the disgust or “ick” factor suggested in some studies as deterring donation (O'Carroll et al., ²⁰¹¹), but a more emotional response to the unknowns associated with having to make a decision about donation while grieving. That emotional response engendered by exposure to a dead human, and dissection of that human, manifested in consideration of a broad range of issues associated with donation. For some, the emotional response will dominate (Morgan et al., 2008; Miller et al., ²⁰¹⁹) but the experience and information that accompanies such exposure in anatomy class does provide a factual base on which to deal with the challenging issues that arise at the time of death.

Thus, the lack of support for self‐ and family‐body donation, and in some participants, organ donation, reported here do not seem to reflect an aversive response. Those participants who had more exposure to gross anatomy were most likely to have thought about donation. In addition, the reasons nominated by participants for not supporting body donation, reflected anxiety about participants' knowledge base, and concerns about future students like themselves handling their bodies, and particularly for a small group of postgraduate students/trainees, the inability to donate organs if they donated their body, rather than antipathy toward dissection. It seems apparent that the participants in the study who had the most exposure to gross anatomy (the postgraduate students/trainees) had been prompted to consider difficult and emotional issues associated with death and donation, and to inform themselves about donation, in a way that those with less exposure had not.

Body donation

The results of this study demonstrate support for self‐body donation is much lower than support for the donation of one's organs for transplantation, and that exposure to gross anatomy reduces support for self‐donation. The concept of body donation was observed to be novel to many participants; more than 40% of the whole cohort had not thought about body donation for themselves; close to 20% had not thought about it in relation to a family member; over 12% also had not considered the issue of public donation. In contrast, only around 10% of the cohort had not considered organ donation for themselves, their family, or for a member of the public. Body donation is less publicly recognized than organ donation (Cornwall, 2011) and overall measures of public support for body donation have not been reported in Australia. Likewise, little is known about public knowledge of body donation and the processes for effecting it. Most body donor programs in Australia do not advertise or promote their programs, and outreach is mostly limited to aged care, general practice, and other geriatric health‐related services. Apart from occasional media reports or first‐hand experience through having a family member donate, the general public in Australia is unlikely to have encountered information about body donation. However, the level of support found in this study is lower than the support reported in some other cohorts or countries with similar practices for procurement of bodies. For example, a 2009 Irish study of post‐graduate medical students prior to their first dissection session reported that around 40% would support self‐donation, although the proportion strongly against self‐donation increased with subsequent dissection session attendance (Perry & Ettarh, 2009). Support for family donation was higher, but both were lower than the support for public donation. The findings reported here are consistent overall (in pattern, if not in proportion) with the low level of support by medical students for self‐body donation, somewhat higher support for family‐member body donation, and the highest support for the public to donate their body (Cahill & Ettarh, 2008; Cornwall et al., ²⁰¹²; Anyanwu et al., ²⁰¹⁴; Galic et al., ²⁰¹⁶; Abbasi Asl et al., ²⁰¹⁷; Kumar et al., ²⁰²⁰). Postgraduate students and trainees who were least willing to self‐body donate were more aware that body donation precludes organ donation, and cited this as a reason not to donate their body. However, 10% of the whole cohort stated that they would not support a family member to donate, suggesting that personal views of next of kin are likely to affect whether an election is honored. This is significant because none of the body donor programs in Australia will accept a body if any of the family or next of kin object.

The use of bodies in education and research is a sensitive issue (Cornwall, 2011; Jones & Whitaker, ²⁰¹²; Ghosh, ^2017a; Jones & King, ²⁰¹⁷), not the least because of the unsavory historic practices for body procurement (Richardson & Hurwitz, 1987; Jones & Fennell, ¹⁹⁹¹; Jones, ²⁰⁰⁰; Jones & Whitaker, ²⁰¹²), as well as contemporary cultural and other beliefs (Richardson & Hurwitz, 1995; Larner et al., ²⁰¹⁵; Ghosh, ²⁰²⁰). Practices aimed to address concerns about dignity and respect for the deceased, and the respectful, compassionate handling of the body by students are integrated into the pedagogy and policies of many gross anatomy courses (Ghosh, 2020) including those at The University of Sydney. However, for some, the use of bodies for dissection, notwithstanding their value in education and research, is distasteful and unacceptable (Ghosh, ^2017b, 2020), a view that may be reflected in the low overall support for self‐ as opposed to public body donation reported here.

Religious practice and donation

There were clear differences between the views of students from different cultural, ethnic, and religious backgrounds in this study toward donation. It was found that participants who practiced a religion were more likely to decline to support body and organ donation for themselves and their family. The association between religious beliefs and reluctance to donate has been reported previously in both Australian (Edwards et al., 2007; Wakefield et al., ²⁰¹¹; Alexander et al., ²⁰¹⁴; Phillipson et al., ²⁰¹⁵; Ralph et al., ²⁰¹⁶) and international cohorts (Rumsey et al., 2003; Wong, ²⁰¹⁰; Galic et al., ²⁰¹⁶; Ciliberti et al., ²⁰¹⁸; Zhang & Ma, ²⁰²⁰). This study suggests that the way in which the deceased body is viewed, and the need to adhere to cultural and familial norms are factors that engender reluctance to support both body and organ donation. The higher value placed by some cultures on rituals associated with death, and regarding the body as sacred, and, therefore, needing to be intact for funeral rites may be particularly significant for these groups (Wong, 2010; Ralph et al., ²⁰¹⁶; Sasi et al., ²⁰²⁰; Donate Life, ²⁰²²) and reflected in the reasons they selected to explain their unwillingness to donate. Local and English‐speaking participants in this study were more likely to regard their deceased body and organs as having no value after death, a view to which their religious and non‐English‐speaking peers were much less likely to subscribe. These same students, nevertheless, expressed some discomfort with the concept of body donation and concern about having others like them dissect their body, again suggesting a very personalized response to body donation.

Most religions in Australia have issued public statements of support for donation by religious leaders confirming that donation does not violate religious codes, including those of followers of Buddhism, Hinduism, Islam, and various Christian religions (Donate Life, 2021). However, misconceptions about donation persist within some religious, cultural, and ethnic sub‐groups (Cooper & Taylor, 2000; Shaheen, ²⁰⁰⁹; Wong, ²⁰¹⁰; Phillipson et al., ²⁰¹⁵; Ralph et al., ²⁰¹⁶; Sasi et al., ²⁰²⁰; Dagcioglu et al., ²⁰²¹) and have significant detrimental impacts on the capacity of transplantation services to provide organs for culturally diverse patients (Ralph et al., 2016). Australian data show that consent rates for organ donation are much lower in some ethnic and religious communities, including those with a greater clinical need for transplantation, and that there are many fewer registered donors (Donate Life, 2022). Although organs from ethnically diverse donors can be used in recipients of different ethnicity, the success rate for matching is lower due to specific combinations of blood and tissue type being more commonly required in ethnic groups (Khanal et al., 2018).

Morgan et al. (2013) completed a systematic review of both qualitative and quantitative literature examining attitudes to organ donation and donor registration in ethnic minority groups across the United States and the United Kingdom. They reported five areas where ethnic minority groups' attitudes or knowledge constituted barriers to positive attitudes to donation and effective registration: (1) low levels of factual knowledge about donation and registration as a donor; (2) familial factors including reluctance to discuss donation with family members, taboos about death, and respect for parental authority; (3) religious and cultural beliefs, including that donation was prohibited by particular religions; (4) concerns about bodily integrity including the need for rapid burial and an intact body (often in conjunction with cultural and religious beliefs); (5) distrust in healthcare systems and doctors, including in relation to receiving optimal treatment and equitable distribution of donated organs. This study suggests these barriers to donation may exist for some of the participants in this study, particularly those from religious and cultural groups who may be local students of immigrant background, or international students pursuing education in Australia, and may also apply to body donation. The much greater level of support of participants from English‐speaking backgrounds for organ donation also suggests that cultural and societal factors such as the widespread promotion of, and support for, organ donation in Australia and other English‐speaking countries (e.g., the United Kingdom and the United States) may also be influential in laying a foundation of positive attitudes to donation. The idea of reciprocity reflected in the selection of the “I hope if I need one someone donates for me” as a reason to support organ donation by local and English‐speaking participants may also reflect both this promotion and trust in their health systems to manage organ donation equitably and for those in most need.

Value of exposure to anatomical sciences

The exposure to anatomical study is likely to be a positive factor in enabling participants to become more competent in providing factual information and support to family members and the public about donation, and in taking steps to make their own election to donate organs effective by registering as a donor. However, it may dissuade or affirm a reluctance in some for self‐body donation. These observations confirm the value of exposure to anatomical sciences over and above the educational value. It is well established that ignorance is a barrier to the use of human tissue: the community and donors have a limited understanding of the processes for donating body, and how they are used (Fennell & Jones, 1992; Richardson & Hurwitz, ¹⁹⁹⁵; Boulware et al., ²⁰⁰⁴; Ciliberti et al., ²⁰¹⁸; Champney et al., ²⁰¹⁹). Ignorance may also inhibit the capacity of health professionals to effectively counsel family about body and organ donation (Schaeffner et al., 2004; Zhang et al., ²⁰¹⁴), and to inform potential body donors of the implications of donation, including the possibility of permanent retention of body parts, and/or the likelihood that their body will be used for education, not research (Fennell & Jones, 1992; Chung & Lehmann, ²⁰⁰²; Larner et al., ²⁰¹⁵; Champney et al., ²⁰¹⁹; Farsides & Smith, ²⁰²⁰). Barriers to effective registration as an organ donor include failure to act upon a positive view of organ donation due to ignorance of the need to register prior to death, and failure to ensure the effectiveness of the election by not discussing the wish to donate with family and next‐of‐kin (Williams et al., 2003; Wakefield et al., ²⁰¹¹; Irving et al., ²⁰¹⁴; Potter et al., ²⁰¹⁷). Ignorance of organ donation processes, in both the community (Sander & Miller, 2005; Newton, ²⁰¹¹; Wakefield et al., ²⁰¹¹; Rokade & Gaikawad, ²⁰¹²; Larner et al., ²⁰¹⁵) and the health system (Irving et al., 2014; Potter et al., ²⁰¹⁷; Keel et al., ²⁰¹⁹) are also associated with lower rates of registration as an organ donor (Schaeffner et al., 2004; Figueroa et al., ²⁰¹³). Research confirms the crucial role friends, family and colleagues have in informing discussion about donation (both body and organ) and registration as a donor (Fennell & Jones, 1992; Conesa et al., ²⁰⁰⁴; Bolt et al., ²⁰¹⁰; Cornwall et al., ²⁰¹²; Larner et al., ²⁰¹⁵; Phillipson et al., ²⁰¹⁵; Merola et al., ²⁰¹⁶; Cornwall et al., ²⁰¹⁸). Body donors have been found to be motivated to register as a donor through their experience of having a friend or family member donate their body (Fennell & Jones, 1992; Bolt et al., ²⁰¹⁰; McClea & Stringer, ²⁰¹⁰; Cornwall et al., ^{2012, 2018}). Research has also found that potential donors and indeed the general community find initiating conversations about donation with their family and next‐of‐kin difficult, and sometimes unacceptable (Phillipson et al., 2015; Ralph et al., ²⁰¹⁶); the specter of loss of someone dear prompts emotional responses which may be overwhelming and prevent discussion. The lack of factual knowledge about donation, particularly the process of procurement, is thus a barrier to donation and inhibits the capacity of the community and healthcare workers to support donation.

This research suggests significant potential in the opportunity of anatomy class as a forum to provide factual information about donation, giving students a knowledge base that may assist them to make an informed decision for themselves. Possessing such knowledge is also likely to improve their competency and confidence in providing accurate information about donation to their friends and family now, and to their patients and the community as they move into their future careers. The experience of encountering a donor body may be an additional factor promoting contemplation of issues about death, the handling of the deceased, and the role of donation in education, research, and training. It may also generate opportunities for further discussion about the potential use of donated organs and tissue, and the role of health care professionals, and medical researchers in supporting the transplantation system, and enabling these life‐saving procedures. While students, of all backgrounds, may find these discussions and thoughts initially confronting, they are possibly more receptive to thinking about them as a consequence of the exposure to the donor body, and the inherent altruistic qualities of donation (Cornwall & Stringer, 2009; Flack & Nicholson, ²⁰¹⁷). It would be important, however, that any program about donation included in anatomy class was constrained to the provision of information, not promotion; the issue of donation is very personal and, as shown here and elsewhere, (Rumsey et al., 2003; Shaheen, ²⁰⁰⁹; Wong, ²⁰¹⁰; Wakefield et al., ²⁰¹¹; Phillipson et al., ²⁰¹⁵; Ralph et al., ²⁰¹⁶; Naidoo et al., ²⁰²¹) reflective of cultural, religious beliefs and other factors. Students should not feel pressured to support donation but could be better informed about it, with the provision of facts about the legal and ethical frameworks in which donation is enabled and the implications of donation, equipping them with the knowledge to address misconceptions, including their own, those of their family and friends, and the community. For those participants who did not support either body or organ donation, their move into professional roles, encountering patients and families who support donation, either as donors or recipients of donated organs, may challenge their views and beliefs about donation. The experience of anatomical dissection and exposure to cadaveric tissue provides an opportunity to offer these students knowledge and personal insights that may assist them to manage these challenges. Such outcomes would be of considerable benefit to the students themselves, and the community.

Limitations of the study

There are a number of limitations to this study, and thus the conclusions that can be drawn.

A validated scale to assess knowledge about body and organ donation and which also had the capacity to measure whether respondents had considered these issues was not identified. The new questionnaire developed for this study has not been validated against existing instruments measuring attitudes to organ donation such as the Attitude Scale and Knowledge Scale, both developed by Sander and Miller (2005), or the Organ Donation Attitude Scale (Rumsey et al., 2003). The questionnaire showed good reliability with a Cronbach's alpha = 0.849. However, validation in a different cohort would be desirable.

Another limitation is the possible effect of sampling bias in the cohort selection. The cohort was not intended to be a general population sample, however, the enrolment of students and postgraduate trainees from a health professional and biomedical sciences courses constitutes a potential bias in relation to the key question of the impact of exposure to gross anatomy and attitudes to donation. A recent study (Viljoen & Stephens, 2021) reported that students of biomedical sciences were more positive about body donation than arts students and that postgraduates were more positive than undergraduates. Possibly, participants were more positive about gross anatomy and the use of donated bodies for research and education because of their choice to pursue vocations requiring training in anatomy, rather than their exposure to anatomical examination per se. The value participants place on their anatomical sciences education may also be reflected in positive attitudes to donation, as reported by others (Cahill & Ettarh, 2011; Ciliberti et al., ²⁰¹⁸; Kumar et al., ²⁰²⁰; Lee & Lee, ²⁰²¹; Naidoo et al., ²⁰²¹).

The study did not examine participants' actual knowledge of donation processes, nor their understanding of how donated bodies and organs were used in Australia, or indeed in their home countries if they were not Australian. Some of the differences in attitudes to body and organ donation, particularly for students coming from non‐European/Anglo‐Saxon countries, may be attributable to their experiences of, or concerns about, the practices in their home countries and/or ignorance of the donation practices in Australia.

The anomalies between available avenues for registration as a body donor, and the participants' self‐reported details of registration as a donor highlight the limitation of self‐reported information. It is quite likely that recollection of donor registration details may be inaccurate. Participants may also have felt pressure to support organ donation or to state that they are registered as organ donors because organ donation is regarded as a social good, a phenomenon reported by others (Sehgal et al., 2016). However, the rate of self‐reported registration as an organ donor in this cohort was not greater than might be expected given the registration level in the general population of individuals of a commensurate age. National data (Donate Life, 2022) suggest that Australians in this age group are highly supportive of organ donation, but that actual registration rates are very low (around 8%). Thus, even if there was some inaccuracy in self‐reporting registration as an organ donor, it was probably not of a substantial level.

Another possible source of bias relates to the order of the choices available to participants when answering questions about their reasons for supporting donation, or not. Ideally, the order of the choices should be randomly presented to avoid primacy and recency bias. Randomization was not practical when using a paper questionnaire, and it was important that the online questionnaire replicated the paper one to avoid introducing other potential biases. Although the order was fixed, responses were selected from all options suggesting that the participants were not unduly influenced by the presented order.

CONCLUSIONS

Overall, this study suggests that exposure to gross dissection invokes complex and difficult thinking in students of anatomy with regard to donation, and their support for it. The findings affirm that there is value in this exposure that goes beyond imparting anatomical knowledge; these students grapple with questions and issues that assist them in forming opinions and views about donation that they may carry with them into their professional lives. The findings suggest that exposure of students who are likely to work in the health and biomedical sciences professions to anatomical studies using donated human tissue is an opportunity to develop their understanding of the practices, and value of, body and organ donation. Participation in gross anatomical instruction prompts students to think about these issues and thus to contemplate their own thoughts and attitudes about being a donor, and about donation by their family and the public. There is an inherent value in the exposure of students in health, biomedical, and medical sciences to gross anatomy as a means of opening up discussion about post‐mortem human tissue donation. These opportunities could be used to explore and develop student awareness, knowledge, and understanding of the value of body and organ donation in education, research, and health, and of the legal and ethical frameworks in which these occur in Australia.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest, financial or otherwise.

Supporting information

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Biographies

Rebekah A. Jenkin B.Sc. (Hons.), M.Sc., Ph.D., Dip. Law, is a doctoral student in Anatomy and Histology, School of Medical Sciences, Faculty of Medicine and Health at the University of Sydney, Camperdown, New South Wales, Australia. Her research is focused on the historic and contemporary use of cadavers in education and research, and attitudes to body and organ donation.

Samuel A. Garrett, is an undergraduate student and Dalyell Scholar enrolled in a Bachelor of Arts and Bachelor of Advanced Studies at the University of Sydney, and a research assistant in Anatomy and Histology, School of Medical Sciences, Faculty of Medicine and Health at the University of Sydney, Camperdown, New South Wales, Australia. His research interests range from anatomical history to international relations.

Kevin A. Keay, B.Sc. (Hons.), Grad. Dip. Sci. Med. (Pain Med.), Ph.D., is a professor of neuroscience, Chief Anatomist, and Academic Lead for Anatomy and Histology, in the School of Medical Sciences, Faculty of Medicine and Health at the University of Sydney, Camperdown, New South Wales, Australia. He teaches neuroanatomy and neuroscience to medical, dental, and science students, as well as to postgraduate students and specialist college members. His research interests include: the neurological basis of the transition from acute injury to chronic pain; the neuroanatomy of injury, blood loss, and pain; pedagogical innovation in pre‐mortem imaging, augmented reality, and virtual reality, to enhance neuroanatomical education.

Jenkin, R. A. , Garrett, S. A. & Keay, K. A. (2023). Altruism in death: Attitudes to body and organ donation in Australian students. Anatomical Sciences Education, 16, 27–46. 10.1002/ase.2180