October 13, 2011
Economics, Ethics, and Bodies
— Kevin Boyd
For much of the past week the Chicago media has devoted a significant amount of attention to a policy dispute unfolding at the Cook County Medical Examiner's Office. In short, the Anatomical Gift Association recently approached the Chief Medical Examiner, Nancy Jones, informing her of a 126-year-old Illinois state law that requires unclaimed bodies to be donated to science. On September 27 Jones announced the enforcement of this statute, and gave a time frame of two weeks before unclaimed remains were to be donated to the Anatomical Gift Association. Previously, such bodies were provided a very basic indigent burial at the county's expense.
An intense debate followed, eventually involving Cook County President Toni Preckwinkle. The policy is, as of this writing, still in a state of some flux, but the deep and visceral response that the policy's announcement elicited warrants reflection. I would argue that Jones' initial memo generated such anxiety, and even ire, because it ran afoul of a classic notion of American self-identity, namely autonomy in relation to bodily integrity. The law also potentially pushes against the necessary religious rituals required for proper burial in certain traditions, notably forms of Islam and Judaism.
For some, the policy outlined in the September 27 memo challenges the deeply held notion of the sacred nature of human remains. In certain communities where the bodily resurrection of the dead is taken in its most literal sense, the idea of donation for research would border on mutilation. This is the same position that would lead such communities to refuse consent for organ donation.
The policy has, at its heart, an understandable though inescapably utilitarian aspect to it. Human cadavers are needed for medical education, and there is a shortage of such cadavers. Of course, this problem is nothing new to medicine. As medical education became more scientifically oriented during the nineteenth century the shortage of available human subjects for dissection created a flourishing underground market for freshly buried human bodies. In contemporary times there remains a shortage of acceptable bodies for basic anatomy courses. For this reason, the state intervened some 126 years ago.
At this point an issue of medical education became intimately linked with economics and ethics. The original statute was designed in order to save the county money by donating bodies instead of providing them with an indigent burial. This raises questions about justice and power, since the bulk of the population of unclaimed bodies come from the ranks of the marginalized and the economically underprivileged. In recent years Cook County has reported providing around 200 such indigent burials per year. Not surprisingly, in the current depressed economic times these numbers are rising, affecting already tight municipal budgets. Last year Illinois Governor Pat Quinn attempted to end related programs that offered state assistance in burials for those on Public Aid, proposing either cremation or donation instead. That initiative was abandoned in the face of strong protests from funeral directors and coroners.
It is troubling that the September 27 memo did not discriminate between unclaimed remains and the remains of those with families who could not afford burial or cremation. Thus the poor have no choice; if they cannot afford burial, the remains of their loved one are gifted to the Anatomical Gift Association. One could argue at this point that the body has become a commodity through a mechanism controlled and determined by the state. This raises one of the fundamental questions of bioethics: Under what circumstances, if ever, can the state make determinations about human bodies? To put it another way, who has rightful authority over a body after death?
More fundamentally, the issue challenges individual autonomy, a sacred pillar of American self-identity, particularly in the context of medical care. For years autonomy was the buzz word in bioethics. Given the sense of individualism that is considered so quintessentially American, it is no surprise that autonomy rests firmly entrenched in most of the models of moral decision-making in clinical contexts.
Here the autonomy question is front and center because the deceased likely did not, on their own or through a proxy, indicate a desire to have their remains donated for scientific research. The question is one of consent. In the recent history of American medical practice this question is resolved by continuing in the long lineage of volunteerism. In this sense individuals are free to choose to donate their organs, not to donate their organs, or not to make a decision about donation. Explicit consent of the patient or her proxy is required. The policy of the September 27 memo takes a decided turn from that trajectory, towards what looks more like a European model of presumed consent. Here a given answer is assumed (in this case a consent for donation) unless the patient expressly gives the opposite. In this move two crucial shifts occur. The ability to not make a decision is removed, and the state mandates a default answer, which is donation. In the technical sense, the agency and intention of the individual is removed; it is, strictly speaking, not a question of an individual making a donation of self out of benevolence, but the state making a donation of its inherited property.
The pivot point of this dispute seems linked both to this issue of ownership and of time. For the state to assume the stewardship of an unclaimed body and provide it with a burial after an extended time appears benevolent. For the state to claim ownership of a body after two weeks and gift it to a third party seems proprietary.
Kevin Boyd is the Director of Field Education at the University of Chicago Divinity School.